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Walter E. Fernald 
State School 

Waverley, Massachusetts 







Instruction of Attendants 


The I 





fffje #lb Comer ^oohtoxt 

r %3 

Prepared by a sub-committee of the Medico-Psychological 
Association appointed at a branch meeting held in Glasgow 
on February 21, 1884. 


THIS Handbook has been prepared in the 
hope of helping attendants on the insane 
to a due understanding of the work in which 
they are engaged. It is sought to give them 
such simple notions of the body and mind in 
health and disease, such instructions for the 
management of those maladies with which they 
are usually brought in contact, and such rules 
for their guidance in matters of every day experi- 
ence, as will enable them to do their work with 
greater intelligence and watchfulness. It is de- 
signed that these instructions should aid attend- 
ants to carry out the orders of the physicians ; 
but it is to be distinctly understood that in no 
• case is anything contained in this book to over- 
ride the special rules of any institution, or special 
orders in regard to any individual case. 

A. Campbell Clark, Convener. 

C. M'Ivor Campbell, 

A. R. Turnbull, \ Sub-Committee. 

A. R. Urquhart, 



I. The Body: its General Functions and 

Disorders 7 

II. The Nursing of the Sick 45 

III. Mind, and its Disorders 72 

IV. The Care of the Insane 98 

V. The General Duties of Attendants . . 121 








ALTHOUGH all animals having a back- How man 
1 r i • i , i i differs from 

bone are fashioned on the same general tne lower ani- 

plan, man differs from the lower animals in his mas * 

outward appearance, internal structure, habits 

of life, and faculties of mind. 

In outward appearance there is this notice- 
able difference, that of all animals man only 
walks erect ; in internal structure, his brain is 
more highly elaborated, — consequently, in his 
habits of life he is widely different, and in the 
development of his mental faculties he is supe- 
rior to all other animals. 

We see in a healthy man a uniform plan, a His external 

it r r l r appearance. 

shapeliness ot torm, and an arrangement ot 
parts closely knit and working in harmony. 

The parts are the head, the trunk (or body), His parts and 
and the limbs; and they are jointed together 301 



so as to form one complete fabric, the human 

These parts are themselves made up of 
smaller parts. The head is composed of many 
small bones firmly welded together ; the trunk 
is many-jointed ; and the limbs have elbows, 
wrists, hips, knees, ankles, etc. All these are 
the joints of the skeleton or bony framework, 
which is composed of nearly three hundred 
bones arranged and jointed together in human 
form, strong to withstand muscular strain, to 
resist external violence, and to protect internal 

internal A deeper inspection reveals that the body 

is not solid, as it appears to be from with- 
out; but that it is hollow, and divided into 
two cavities, the one large and the other 

Cavities and The larger is the cavity of the trunk (or body 

organs. ° J v J 

proper), and contains the organs of nutrition ; 
the smaller is the cavity of the head and back- 
bone, and contains the organs of the nervous 

The body cavity is divided by a parti- 
tion into an upper (chest or thorax), which 
lodges the heart and lungs, and a lower 
(the belly or abdomen), which lodges the 


liver, stomach, kidneys, bowels, and other 

The cavity of the nervous system consists of 
two divisions : First, the skull, which accommo- 
dates the brain ; and second, the back-bone, 
which lodges the spinal cord. 

The contents of these cavities have been 
called organs ; each organ is implanted there 
for a special purpose or duty, and the duty of 
the organ is called its function. 

These cavities contain the greater part of The . machin - 

1 ery m mo- , 

the machinery of life : and could we but peep tion, "wheels 

J . within 

within, what a busy scene would present itself ! wheels." 
the pumping of the heart, the respiration of 
the lungs, the digestion of food, and the other 
movements necessary to life. These move- 
ments are complementary to each other : the 
organs of digestion and respiration supply 
nourishment to the circulation ; the circulation 
distributes nourishment to all parts of the 
body ; the hungry tissues feed upon this nour- 
ishment, and throw their refuse back into the 
circulation ; the circulation discharges its waste 
matter into the channels provided for draining 
it away ; and, last of all, these movements are 
regulated by the nervous system, which exer- 
cises a direction of all the other functions. 



Of these functions, let us first understand 
the circulation of the blood, " the river of 
Theheartthe The heart is the beginning and end of the 

centre of the . 

circulation, circulation. Placed in the thorax, between the 
lungs, it is a hollow organ, the size of a closed 
fist, and shaped like a pear. It contains four 

its size, small chambers, quite enclosed and separate 

shape, com- _ , r 

partments, from each other ; two 01 these are upper, and 

and connec- T 1 . . ■"' 

tionswithar- two lower. It has been compared to a iorce- 
veins. pump, for, like a pump, it is a receiver and dis- 

charger, and is fitted with valves. It receives 
blood and discharges blood. The two upper 
chambers (called auricles) are the receivers; 
the two lower (called ventricles) are the dis- 

Now, from the heart to all parts of the body, 
two sets of pipes are laid down, which dimin- 
ish in size the further they lie from the heart. 
They are not unlike india-rubber tubes to the 
touch, but many are so small as to be seen 
only under the microscope. Those pipes 
which convey blood from the heart are called 
arteries, those which convey blood to the heart 
are call veins, and there is an intermediate or 


junction set called capillaries, which are the 
smallest of all. 

The upper chambers of the heart, being the 
blood receivers, are connected with the veins. 
These chambers lie side by side, and are there- 
fore right and left ; two large veins open into 
the right, and two into the left. In like man- 
ner, the two lower chambers, being dischargers 
of blood, are connected with arteries, one 
artery passing from each ; and the lower cham- 
bers are also placed right and left. The right 
upper chamber communicates with the lower 
chamber of the same side by an opening in 
the partition. This opening is guarded by 
valves, which prevent blood passing back- 
wards after it has once entered the lower 
chamber. Precisely the same arrangement is 
seen in the left side. The veins which pour 
their blood into the right upper chamber have 
drained blood from every part of the body • 
this blood is dark red, and impure ; it passes 
downwards from the right upper chamber to 
the lower, and is prevented from returning by 
the valves. It is then forced by the muscle 
of the heart out of the right lower chamber 
into a lung artery ; this lung artery divides into 
two, one branch going to each lung. In the 


lungs the blood is purified, and it comes back 
The blood is by veins bright and red to the left upper cham- 

purified in J ° rr 

the lungs, ber of the heart. It then passes to the left 
lower chamber, which forces it into a great 
artery called the aorta. This artery breaks 
up into many branches, which carry the pure, 
healthy blood to every part of the body. 

Bleeding When a vein is opened, dark red blood flows 

from arteries . . 

and veins dif- in a continuous stream from it; but when an 
artery is wounded, bright red blood squirts out 
with every pulsation of the heart, for, while 
the flow in the veins is slow and constant, in 
the arteries it is quick and jerky. 
The struc- The healthy lung resembles a sponge, for it 
lungs. can be squeezed into small bulk, and when 

pressure is removed it expands. 
Clusters of The chief cause of the expansion is elasti- 
semW e s clus- city, and this elasticity is mainly due to a 
grapes. peculiar structure, which is only seen in the 
lungs, and which consists in the grouping to- 
gether in clusters (like grapes) of extremely 
minute air-cells which are elastic. These air- 
cells are connected with the wind-pipe, and 
when air is breathed it rushes into all the air- 
How the cells. Now, over the surface of the air-cells 

blood is puri- 
fied in the run very small arteries carrying impure blood. 

The air and the blood make an exchange ; the 


air gives oxygen gas to the blood, and the 
blood gives carbonic acid gas to the air. 

Fresh air contains a large supply of oxygen 
gas ; respired air is impure, for it contains a 
poisonous quantity of carbonic acid gas. Th or- The necessity 
ough ventilation admits a plentiful supply of ventilation. 
fresh air, and expels an equal quantity of bad 
air. It is therefore important to secure free 
movements of air — of fresh inwards, and im- 
pure outwards. In this way only can the 
lungs be well supplied, and do their work thor- 

As the chest rises the lungs expand and fill 
with air ; as it falls they contract and expel air. 
The lungs, in order to work their best, must 
expand well ; and therefore not only must the 
chest rise well, but there must be no choking 
up of air-tubes or air-cells. 

Here, then, is the plan of the circulation and The circuia- 

, T • ' . r . 1 Hi tion and res- 

tne respiration, for these cannot well be con-ph-ation are 
sidered separately. The great centre of the connected, 
circulation is the Heart ; the great centre of 
the respiration is the Lungs. 

Every drop of blood is pumped out of the Two drcuia- 
heart twice for once that it flows through the circulation 118 
body. Where does it go the second time ? It circulation. y 
goes to the lungs to be purified. We have 


therefore to distinguish two circulations, a lung 
circulation and a body circulation. If we follow 
the blood from the heart, where it flows into 
the aorta, and trace it passing from larger into 
smaller arteries, thence into capillaries, and 
then into veins, we will find that as it flows 
along it distributes nourishment, and in ex- 
change for the nourishment it drains away 
waste matter from the various organs through 
which it flows. In proportion as it receives 
does it give forth nourishment, but having 
reached the veins its supply is exhausted, the 
bright red color is gone, it is loaded with 
waste, and therefore impure. 
The drcuia- The blood which has left the heart pure, 

tion is to the 

body both a therefore, comes back impure ; the oxygen 

feeding sys- . . 

tem and a which it took from the lungs is given to the 

drainage sys- . . . . . 

tem. body to maintain lite ; the carbonic acid 

taken from the body must be carried to the 
lungs, to be thrown off at every breath. 
Therefore it leaves the heart a second time 
and passes into the lung circulation, and if 
we follow it there, we find that it becomes 
purified by taking up oxygen from the fresh 
air, and throwing off a great deal of its waste 
matter, which is breathed into the outer air by 
the lungs. It then returns to the heart, and 


is now fresh for nourishing the body again. 
It does not derive all its nourishment from the 
lungs, nor does it give all its waste to them, 
but this will be explained by and by. You 
will therefore understand that there are two 
distinct and separate streams of blood in the 
body, a short circular stream between the 
heart and lungs, called the lung circulation, 
and a longer stream and wider circle, called 
the body circulation. 

We must now inquire whether the heart 
alone is sufficient to keep up this perpetual 
circulation of blood day and night. 

Is a pump all that is required? Our an- The heart 
swer is No. Although the heart is as neces- workwithout 

r ,1 i ,• v 1 r assistance 

sary for the circulation as our limbs are iorf rom i ungs> 
movement, it requires to be assisted, and musc es ' etc * 
could not do its work without assistance. 
The heart is the force which sends the blood 
out of the heart, but muscular exercise and 
bodily vigor must help it back again. If the 
heart receives blood slowly and feebly, it must 
pour out blood slowly and feebly, and thus the 
circulation loses its vigor and the body is not 
well nourished. Three things are necessary 
for a vigorous, healthy circulation : First, a 
sound heart and vessels. Second, vigorous 

1 6 THE BODY. 

functions in every organ, especially in the lungs. 
Third, muscular exercise. 
The pulse, Let us now consider the state of the circula- 

how it is pro- . , . » 

duced, its tion as we may observe it in our patients ; and 
guide to in order to understand the differences that 

know how • t rr • l • i 

the heart and are seen m dinerent patients, let us consider 
work. the pulse. Every volume of blood pumped 

by the heart into the arteries produces a pulse, 
so that for every heart-beat we should have a 
pulse-beat. The pulse is therefore a valuable 
guide to the study of the circulation ; it en- 
ables us to judge how the heart does its work, 
whether it pumps too slowly or too quickly, 
whether it is strong or weak, steady or un- 
steady. The average pulse for a man is 70 ; 
for a woman, 80. 
Signs of If you examine your patients carefully, you 

latlon ob- CU " will find that some have small, languid, or in- 
asylums? termitting pulses, cold, blue, and swollen 
hands and feet. These are signs of a feeble 
circulation ; and, as you might expect, there 
Feeble drcu- is no vigor in their systems, the respiration is 

lation may be 

due to the shallow and feeble, the muscles are idle, — 

mental con- . . ... 

dition, weak everything that makes a vigorous circulation 

health, heart . . _ , - . .. . . 

disease, or is wanting. Rub that patient all over and ob- 
serve how the skin glows, how warmth comes 
to the surface, and how the pulse gains force ; 


or put him in bed and you find that the circu- 
lation improves, because there is less obstruc- 
tion to it when lying down. Again, give him 
half an hour's vigorous exercise, so that every 
muscle comes into play and propels the blood 
along the veins towards the heart, and you 
get the same result ; the circulation quickens, 
the body calls out for more nourishment, the 
brain is wakened up, and the patient's whole 
condition is very much improved. But your 
patient may have been excited and gone 
through much exercise ; he has not had 
enough of food, nor enough of sleep; his 
heart is faint, and his breath short from sheer 
exhaustion ; his circulation is feeble and he 
needs rest in bed. He may be old and fee- 
ble, or suffering from heart disease, and there- 
fore unable for vigorous exercise, as his heart 
cannot stand the strain. The doctor will di- 
rect in these cases what is best for him. 

You will frequently observe how shallow signs of 
the respiration is, and how blue or gray the rationoriung 
face, hands, and feet appear. You will ob- isease * 
serve sometimes a bright red spot on each 
cheek, a cough, a spit, a shortness of breath, 
a wasting of the body, pain in the chest, and 
night-sweats. These you will do well to notice 

1 8 THE BODY. 

and report; they usually mean disease of the or- 
gans of respiration. There may be merely a fee- 
bleness of respiration, just as there is a feeble- 
ness of circulation, because of the stupor of 
mind into which a patient has fallen, and 
you will be told that your patient wants rous-' 
The causes of ing and muscular exercise. But there are 
ung isease. cases a ] g0 Q £ ac t ua } \ un g disease, and such 

diseases are common in asylums ; they may 
be due to bad ventilation, to cold and damp, 
insufficient exercise when out in the open air, 
sitting exposed to cold biting winds or lying 
on damp grass, or against wet supports, es- 
pecially after perspiring. Lung diseases are 
especially apt to attack miners, masons, and 
persons who work in a dusty atmosphere, or 
people who are confined all day long in un- 
healthy rooms or in a stooping posture, and 
who therefore do not get a sufficiency of pure 
air, and free play for the lungs. The insane 
Prevention is are verv liable to lung diseases for some of 

better than J ° . 

cure. these reasons. Patients who are in delicate 

health, who have narrow chests, very little fat, 
and feeble circulations, should be specially 
guarded against the risks of lung disease. 
Two duties here devolve on you. First, pre- 
vention is better than cure ; therefore protect 


your patient from the causes of lung disease, Symptoms 
j ^ & > should be ob _ 

or, better still, prevent or remove the causes, served early 

and reported. 

if possible. Second, be on the lookout for 
symptoms, and report them at once. 


The exercise of the bodily functions is, While we 

live we waste 

accompanied by wear and tear, and requires and undergo 

, repair. 

to be sustained by nourishment. Thus the 
body is the seat of two opposite processes 
which ought to balance each other : the one is 
waste, the other is repair. 

Idleness means rust and decay, work means Every organ 

, , . ill and tissue is 

wear and tear ; so that in every case the body a small fur- 
loses substance, and the harder it works it tributes its 
loses the more. It lives and labors at a sacri- heat 6 of° the 
fice of itself ; for every tissue while it lives con- ° y * 
sumes, and is fed with fresh fuel. This burn- 
ing is the cause of the heat of the body. As 
the intensity of the fire so is the temperature, 
and, to reason upside down, as the temperature 
so is the burning or waste. A high tempera- 
ture, therefore, means increased waste, and 
proves the necessity for extra repair. Every 
organ, every muscle, every tissue, has its ash 
or waste, and these ashes require to be col- 
lected and drained away by the circulation, so 


that the working of the system may not be 
clogged and thrown out of gear. 
The drcuia- The circulation is the drainage system, and 

tion collects . . . 

and dis- it empties the refuse in three ways : into the 
refuse. lungs, the sweat-glands, and the kidneys. The 
lungs expire it, the sweat-glands perspire it, 
and the kidneys flush it as urine into the blad- 
der, thence to be passed at intervals. Hence 
the advantage of free and easy respiration, of 
a clean, healthy skin, and a proper discharge 
of urine, all of which ought to be seen to by 

The food we eat is the raw material out of 
which repairs are executed. In order to ren- 
der the process easier, it is first cooked, and 
being introduced into the mouth the machinery 
of repairs is set in motion. 
Repairs pro- Repairs are executed in four stages. The first 

ceed by . 

stages, (i) is chewing and swallowing. The mouth is the 

swallowing, mill which grinds the food and softens it into 

(3) abforp° n ' pulp. The smaller it grinds and the moister 

ing)(4) S Ssi-the pulp, the easier will the food digest. In 

conversion^, this stage five things are necessary if the mill 

is to work well : these are a good array of teeth, 

busy jaws, abundance of saliva, plenty of time, 

and a healthy swallowing apparatus. The 

second stage is digestion, which is carried on 


in the mouth, stomach, and bowels. Digestion 
is performed by five juices, which attack the 
food, each in turn as it is propelled along, 
until at last it is very finely divided and so 
altered in chemical character as to be easily 
absorbed and fit for nourishing the body. The 
digestive juices are (i) the saliva, which acts 
on the starchy foods ; (2) the gastric or stomach 
juice, digesting such things as white of egg, 
lean meat, and other albumens; (3) the bile, 
which enters the bowel by a passage from the 
liver and reduces fats to a state fit for absorp- 
tion ; (4) the panc?'eatic juice, which enters the 
bowel by a passage from the pancreas (or 
sweetbread), and acts on albumens, changes 
starch into sugar, and reduces fats to a state 
fit for absorption ; (5) the intestiftal or bowel 
juice, which acts on the food in a way similar 
to the pancreatic juice. These juices are pre- 
pared in little pouches called secreting glands, 
which extract from the blood the material 
necessary for the manufacture of the juices. 

After the food is swallowed, we find it in 
the stomach, and the gastric juice playing 
over it. The stomach is kept in unperceived 
motion, for it is a muscular bag, so that every 
particle of food is rolled about, and freely ex- 

2 2 THE BODY. 

posed to the action of the juice, which having 

finished its work, the food passes into the 

bowel, to be subjected to a further process of 

six things digestion. Six things are necessary for a good 

necessary for . ' x . 

a good di- digestion : (i) the food must be finely divided 
and soaked with saliva ; (2) the muscular move- 
ments of the food passages (mouth, gullet, stom- 
ach, and bowels) must be active and ready at 
call ; (3) the blood must abundantly supply the 
secreting glands which manufacture digestive 
juices, and therefore the circulation must be 
rich and vigorous ; (4) the secreting glands 
must prepare an abundance of juice, but they 
cannot do this if the stomach is disordered and 
their function sluggish ; (5) the body must rest 
before and after meals ; (6) the mind should be 
tranquil, and the patient should, as far as pos- 
sible, have bright and cheerful surroundings. 
Next comes the stage of absorption or strain- 

The process ing. The digested food is strained through the 

Son! lining of the stomach and bowels, taken up by 

the blood-vessels and carried into the circula- 
tion. The undigested food and other refuse 
are expelled from the bowels as stools or faeces. 
The fourth and last is the stage of assimilation 

The stage of or conversion, or, in other words, the taking from 
the blood of particles of nourishment to repair 


waste places in the organs or tissues of the 
body. These particles become converted into 
part and parcel of the tissue itself, and are, 
therefore, said to be assimilated or made simi- 
lar to the rest of the tissue. 

A word may conveniently be inserted here The appetite: 
respecting the appetite, a most important mat-ance? P ° 
ter for us to consider, as it is often an index of 
good digestion. Indeed there is no necessity 
for a good digestion if there is nothing to di- 
gest, and there will of course be nothing to 
digest unless the patient feeds. 

The appetite is influenced by the state ofitisinflu- 
the mind as well as by the state of the body, state of y th e e 
You scarcely require to be told that grief para- "s^h/state 
lyzes the appetite; that joy or excitement is° l e bo y * 
apt to create a hasty, impulsive appetite that 
bolts food, half chewed and difficult of diges- 
tion, into the stomach. Some are over-greedv, 
others are small and dainty of appetite. A few 
cannot eat at all if distracted by the presence 
of other patients. Some prefer to eat out of 
sight, and others cannot eat if they are hurried 
at meals. We must not forget that delusions 
may have a bad effect on the appetite ; a pa- 
tient may be hungry and yet refuse food, believ- 
ing that it is poisoned, or he may refuse food 


from the belief that he has no stomach at all 
If we now turn to examine the bodily causes 
of want of appetite, we shall find that they are 
equally numerous. As examples, we would men- 
tion lack of energy and of open-air exercise, 
sluggish liver and bowels, and disorders of the 
stomach. Enough has been said to prove the 
importance of studying the appetite and search- 
ing carefully for the causes of want of appetite. 
Sleep is a Sleep has been well described as "closing 

" closing for 1 • 11 1 • i-i -t 

repairs"; the for repairs. A snip while sailing is more or 

body requires , , , . ... , 

to "lay up" Jess undergoing small repairs; but in order to 

at regular in- . /, , , , . . ,, 

tervais. receive a thorough overhaul she requires "to 
lay up." So is it with our bodies. While we 
are awake and active, repairs are going on, 
but the supply soon falls short of the demand, 
and the body requires to lay up when night 
comes, so as to make good the deficiency in 
time for the next day's work. During sleep 
the body rests from its labors ; the brain ceases 
to think, feel, and will ; the muscles and nerves 
rest themselves, and the circulation, respiration, 
and digestion, " take it easy." And now repairs 
go on more quickly, gaining ground on the rav- 
ages of the day, until man rises from his slum- 
bers in good repair, fresh for new work and 
another voyage. Sleep is clearly a necessity 


of life. No man can afford to neglect it, and 
all will do well, by attention to nature's laws, 
to secure a needful supply of it. 

Sleep is encouraged by exercise in the open Practical 


air. The old proverb is worth remembering : — 

" After dinner rest a while, 
After supper walk a mile." 

It is also encouraged by regular hours, quiet- The body is a 

. i bank-account 

ness, calmness of mind, a cool, airy bed-room, of waste and 

i r repair. 

and a comfortable bed, etc. 

A man's body, then, is simply a bank-account Aman cannot 

r -i j r , i rr-ii afford to be 

of loss and gain, of waste and repair. 1 he miserly or 
more he takes out of himself, the less he has wthhkbodi- 
to spare, and the more he requires to make up. y su stance# 
But a man must not be a miser with his sub- 
stance ; he must not go on feeding full time, 
and only working half or quarter time. Nor, 
on the other hand, must he be profligate, work- 
ing double tides, and only patching his repairs. 

Every organ must have reasonable exercise, He may 

, , «iii i , i waste too 

and waste and repair should regulate each much or too 
other. We are here again face to face with our l 
duties to the insane ; for many of them have 
overdrawn their bank-account, and we must trv 
to recover the balance. 

A great deal lies in our power to remedy this 
state of matters. The risk of death from ex- 



haustion is often great; and sound, refreshing 
sleep and frequent meals are absolutely neces- 
sary to tide over the crisis. 
How much Appetite and sleep must be promoted ; and 


can help in on attendants carefully observing any causes 

CI 1I1C3.1 C3.SCS 1*11*1 i i c • i c 1 1 • 

where ex- which hinder these, and faithfully reporting 

haustion is , , , , 

threatened, them, as well as conscientiously carrying out 
the doctor's orders, will depend the recovery 
of the patient if it is at all possible. In deal- 
ing with patients who waste quickly, the re- 
sponsibility of the attendant is increased ; but 
when every effort is put forth for the patient, 
recovery is so often a certainty that in the end 
the attendant's satisfaction exceeds his respon- 
sibility. Here is placed side by side a scale 
of waste and a scale of repair, which should 
be as carefully calculated as possible : — 

Scales of 
waste and 


[Signs of Increased Waste?) 
i. Loss of weight and ap- 

2. Excitement, if severe or 


3. Loss of sleep. 

4. Increase of temperature. 

5. Discharges, such as diar- 

rhoea, vomiting, matter 
from sores, spit, etc. 

6. Loss of blood. 


[Signs of Increased Repair.) 

1. Increase of weight and 


2. Excitement ceasing. 

3. Sleep gaining ground. 

4. Temperature reduced. 

5. Arrest of discharges. 

6. Arrest of bleeding. 

inquired for 



Two may differ as to what a good meal is, Loose state- 
ments to be 
but a plate of porridge is always a plate of avoided by 

. 1 • ' i • attendants in 

porridge, and a pint of custard is always a pint reporting ob- 

. servations. 

of custard. A man may not seem to be gain- 
ing or losing weight, but the steelyard will tell 
to a pound yes or no. We do not always know Details to be 
what an attendant means by a good sleep, but 13 
we know what " seven hours " mean. The 
habit of careful observation and statement 
must go into other details as well. 

(1) The appetite. Various causes affect it, 0) of the 


and these should be carefully looked for. The 
association with other patients sometimes wor- 
ries or excites, so as to paralyze appetite. 

Some patients appear never to miss a meal, 
and yet, having appetites little better than a 
bird's, are too easily satisfied. Others are slow 
or timid, and hurry over their meals when they 
are served by an attendant whose whole thought 
is to clear the table with the greatest possible 

An observant attendant will distinguish be- 
tween the patient who eats till he is sick and 
the patient who works hard and requires an 
extra allowance. Lastly, great care and pa- 



(2) Of the 


(3) Of the 

tience are required with those who have few or 
bad teeth, epileptics, paralytics, and those who 
"bolt" their food. These should never be 
hurried, and their food should be cut small, to 
make digestion easy, and to prevent choking. 

Refusal of food may be the outcome of de- 
lusions, and attendants should find out whether 
such a cause exists. If so, it ought to be re- 
ported. Perverted appetite is illustrated in the 
case of those who eat filth, rags, pig's meat, 
gravel, etc. Such cases call for constant ob- 
servation, and should be immediately reported. 

(2). Digestion. The appetite itself is often 
a sign of good digestion, but among the insane 
it often exceeds the digestive powers. If diges- 
tion is disordered, signs will be observed, and 
ought to be reported, especially abstinence from 
food. Such are foul breath (which may also 
be due to other causes), a foul tongue, bitter 
taste, vomiting, pain or fulness in the region of 
the stomach, heartburn, wind, waterbrash, head- 
ache, etc. 

(3) The bowels. Their condition should be 
daily observed, and the attendant should not 
be satisfied with merely noting that a patient 
goes to the closet ; he should observe whether 
he has a stool or not, and how often, whether 


it is abundant, easy or difficult, watery or hard, 
light, dark, or bloody, and whether there is 
present any indigestible or undigested matter, 
buttons, coins, etc., and whether there are 
worms. Lastly, patients who suffer from rup- 
ture require always to be easy in their bowels, 
else death may ensue after a few hours' notice, 
or a serious surgical operation be necessary. 
The mental condition is often affected by the 
state of the bowels, and among the insane 
careful attention in this respect is necessary. 

(4) The urine may not be passed often ( 4 ) of the 
enough, or it may come too often; it may be 
abundant or scanty, pale, high-colored, or 
bloody, or its flow may be attended with diffi- 
culty or pain. If the urine is not voided for 
twenty-four hours or more, the patient's condi- 
tion becomes serious till relief is obtained. It 
is to be noticed that paralyzed patients may 
suffer from such retention, and patients like- 
wise who are in a state of stupor. 

(0 The skin should be noticed when bath- (5) of the 

. . . skin. 

ing is being conducted. Observe whether dry, 
or moist, or bathed in perspiration, and at what 
times. Examine for lice, eruptions, sores, or 
marks of injury. 

From what has now been said, other hints 


may be suggested to you, which, in the course 
of your experience, can be acted on. Enough 
has been stated to enlarge your knowledge and 
to quicken your intelligence. Act up to it and 
you will learn more, and, greatest comfort of 
all, you will immensely benefit the patients 
under your charge. 


The Nervous We now pass on to the nervous system, the 

chief parts of which, as already stated, are en- 

The position closed within the skull and back-bone. The 

and Spinai am brain lies in the top and back parts of the head, 

and connected with it is the spinal cord, which 

lies in the back-bone. From them proceed 

nerves, which branch in all directions into the 

organs and through the tissues, and in this way 

the brain and cord are brought into intimate 

The Nervous relat ion with all parts of the body. The ner- 

w!de-spnJd a - S vous system is therefore as far-reaching as the 

mg branches - circulation, and its influence is everywhere 

The materials manifest. It is composed of three materials 

which com- — g rav m atter, white matter, and cement sub- 
pose It. £> J 9 "> 

stance. In the brain the gray matter forms the 
outer layer, and encloses the white matter, 
through which are scattered clusters of gray 
matter. The gray matter consists of small 


nerve-cells, and the white of nerve-threads, 
which communicate with the nerve-cells. The 
cells and threads are embedded in cement sub- 
stance, which is soft and yielding, and yet acts 
as a protective to the nerve structure. In the 
spinal cord the composition is similar, but the 
gray matter is in the inside, and the white 
matter on the outside. The fibres which 
branch from the cord and brain consist merely 
of nerve-threads enclosed in protecting sheaths. 
The whole nervous system is well supplied with 
blood-vessels, which are more numerous in the 
gray than in the white matter. 

The functions of the nervous system bear a its functions 


resemblance to the operations of the telegraph those of the 


system. sys tem. 

The gray skin of the brain may be compared 
to a great city, the headquarters of the tele- 
graph system, and the gray clusters scattered 
through the white substance of the brain are 
the suburbs of the city, the gray clusters of the 
spinal cord are the towns, and the points of 
skin, muscle, organs, etc., where nerve-fibres 
end are the villages. The nerve-fibres con- 
nect villages, towns, suburbs, and the great city 
with one another ; for no station can exist with- 
out a connection. The fibres are of three 


Three kinds kinds : first, inward messengers; second, out- 

of Nerve 7 i • i • , * 

Fibres. ward messengers ; third, internal messengers. 
Inward messengers may pass from any sur- 
face or organ of the body to the cord or to the 
brain. Outward messengers emerge from the 
brain and cord and pass outward in many 
directions, but they chiefly supply muscular tis- 
sue and cause movements. Internal messen- 
gers carry messages between the brain and its 
suburbs or the cord, or between different sta- 
tions within the city itself. The nervous system 
operates in a variety of ways, of which the 

Examples of following are examples: (i) If the skin is 

how the •ill • 11 i 

Nervous pricked, the nearest village at once sends a 

System oper- . . . , , , . 

ates. message by an inward messenger to the brain, 

and the message is immediately registered as 
we at once become conscious of the sensation 
(the messenger so exercised is called a sensory 
nerve) ; (2) when the brain wills to move a 
muscle, a message is sent outwards to the 
muscle, and at once the muscle contracts (the 
messenger so employed is called a motor nerve) ; 
(3) various operations of the mind take place 
within the brain independently of these ingo- 
ing and outgoing messengers, — and these opera- 
tions consist of communications between centres 
within the brain itself, and are conducted along 


internal nerves ; (4) when the foot is tickled, 
the nearest nerve-terminus sends a message to 
one of the gray centres (towns) of the cord, 
and this centre sends back a message to the 
muscle of the leg to draw away the foot. In 
this case the communication is only a half-way 
communication, and the mind may be quite 
unconscious of it, and because it is sent back 
in the direction from which it came it is called 
reflex (thrown back), and this kind of nervous 
action is called reflex action. These examples 
illustrate some of the principal functions of the 
nervous system, but there are nerve-currents 
of other kinds besides these, which are chiefly 
varieties of reflex action. To these four, how- 
ever, we will do well to pay some further at- 

Sensations are the result of messages con- ( ? ) The func- 
ducted by the sensory nerves to the brain, andsation? 
they vary in kind according to the impression 
applied to the nerve-ends. An impression of 
the finger excites a sensation of touch ; a warm 
bottle to the feet sends a sensation of warmth ; 
a mustard blister a sensation of burning; a 
lump of ice applied to the skin sends a sensa- 
tion of cold : and a prick by a needle a sensa- 
tion of pain. The skin, as you know, is very 


sensitive, and the reason is this, that it is 
crowded by nerves which connect it with the 
cord and the brain, and collect impressions for 
the information of the brain. In this way we 
feel changes of heat and cold, comfort and 
discomfort, cramps and pains ; and not only 
so, but we can put our finger on the spot where' 
the feeling comes from. It is easy to under- 
stand, therefore, that sensation can be pre- 
vented in three ways : (i) By destroying or 
separating the skin so that it ceases to conduct 
an impression ; (2) by disease or injury of the 
sensory nerves ; (3) by disease or injury of 
the brain. To make sensation perfect, these 
three links of the chain must be joined to- 
gether, and be free from disease or injury. 
(2) The Mo- Motor nerves convey messages from the 

tor func- . . 

tions. brain to the muscles, which contract in conse- 

quence. The nerves receive their impressions 
from the will, and respond accordingly. If 
the will is paralyzed, the motor nerves receive 
no impressions and the muscles are not called 
into action. If the nerves are diseased or in- 
jured, the will and the muscles are of no avail ; 
and if the muscles are destroyed or discon- 
nected from the nerve, muscular movement is 
equally impossible. Hence the necessity for 


an unbroken line of connection in good repair. 
When the connection is complete and healthy, 
the will has at its command about five hundred 
muscles, which are arranged in groups accord- 
ing to the movements which they are designed 
to execute. These movements are numerous, 
and of endless variety, and include the delicate 
and difficult movements of speech and writing, 
as well as the coarser movements of walking, 
wrestling, swimming, etc. Running side by 
side, therefore, are two sets of nerves, the one 
sensory, and the other motor, the one conduct- 
ing impressions to the brain, the other con- 
ducting impressions from the brain. 

But within the brain itself there is a third T f ne function 

of mind and 

set of nerves, which begin where sensation the functions 

# .of internal 

ceases and the mind comes into operation, nerves and 

. cells. 

These are the internal nerves, and their func- 
tion is to conduct messages within the brain 
from one centre to another, messages of mem- 
ory, of thought and feeling. 

The internal nerves and the nerve-cells of 
the mind connect with each other so as to form 
a network, which, while we are awake or dream- 
ing, is in a state of busy activity, telegraphing 
ideas from cell to cell. 

In proportion as this network becomes 


broken or weakened does the mind fail in its 
functions; the snapping of a few fibres, the 
sickening of a few cells, makes a serious dif- 
ference ; and because of the delicacy of it, 
the structure requires constant repair and care-, 
ful preservation. The internal nerves, and the 
brain-cells which they connect, vary in number 
in different brains. In the idiot and the im- 
becile they are less numerous, and their num- 
ber is greater in the brains of more perfect 
Reflex Reflex action is a most important function 

functions. . . . - 

of the nervous system. It is independent of 
consciousness, and for this reason is applied 
to regulate functions which, if left to our own 
will and guidance, would be imperfectly per- 
formed, and frequently forgotten. The will is 
not concerned with the movements of the 
heart and lungs ; the function of digestion it 
is scarcely responsible for; and the drainage 
of the human system has no direct relation to 
consciousness or will. Reflex action alone is 
the responsible mainspring of these functions. 
When food enters the mouth, saliva flows over 
it;. when it enters the stomach, gastric juice is 
poured forth. The preparation and the flow 
of these juices are not intrusted to the will, but 


rather to a simple and self-acting nervous ar- 
rangement, which is excited by the mildest 
friction, and which in turn calls into activity 
the juices. The respiration, the circulation, 
and other necessary functions of life are regu- 
lated in a similar way. The withdrawal of the 
foot when its sole is tickled, the winking of 
the eyelids when the hand is quickly drawn 
across the face, and the contraction of the 
pupil when light is thrown into the. eye, are 
other and more familiar varieties of reflex ac- 
tion, which must serve to complete our descrip- 

With these four functions affected by disease Disorders of 

.. , J , , ill Sensation. 

we can easily understand how helpless a man 
becomes. Any one may be alone disordered 
or paralyzed, but it is usual in serious cases to 
find more than one involved. Of sensation 
the most common affections are neuralgia 
(pain in a nerve) and hysteria. Pain of any 
kind is the result of disease or injury in the 
path of a nerve, or at either end of it. A 
nerve-end irritated by a diseased tooth, and 
inflammation alongside a nerve, are examples 
of this. 

But sensation may be abolished, and this is 
sometimes found in hysteria, with paralysis of 


motion, and more or less in epileptic and 
apoplectic seizures. The sensibility of many 
insane patients to pain is more or less im- 
paired, and some are known to derive pleasure 
rather than pain from acts of self-injury, such 
as chopping fingers, lacerating the skin, and 
extracting teeth, which to others would simply 
be torture. 
Disorders of When muscular action is arrested or difficult, 

the Motor . 

System. when it occurs in spasms or quick successive 
jerks, and when it is manifest in trembling in 
place of steady movements of the hands, the 
tongue, or lips, we know that the motor system 
is somewhere affected. The seat of disease 
is sometimes in the cord, but usually in the 
brain, at the starting-point of the motor nerves. 
The nature of the disease varies, and the 
symptoms differ accordingly. These may be 
of the character of paralysis of armor leg, or 
both, dumb palsy, shaking palsy, St. Vitus' 
dance, epilepsy, etc. In general paralysis of 
the insane we see first the motor excitement, 
trembling of the tongue, lips, and muscles of 
the face, the trembling of the hands, and the 
muscular restlessness of the patient. By and 
by the disease visibly advances, the trembling 
and restless movements cease, and, with the 


further progress of the malady, complete pa- 
ralysis and incapacity of movement signify the 
last stage of all. When a patient is seized 
with a paralytic stroke, the power of movement 
is more or less completely lost, and yet the 
disease may only affect a very limited portion 
of the brain. In this case the telegraph sta- 
tion which sends out messages to the muscles 
is destroyed, and, notwithstanding that the 
muscles and motor nerves still remain healthy, 
the messages on which they depend for their 
activity can no longer be produced. 

When the internal nerves and their connect- Derange- 

i • 1 • t ment of the 

ing brain-cells become the subjects of disease, internal net- 

- • ! , 1 . rpi WOrk of 

the mind soon tell its own story. 1 he connec- nerves and 

r , , . , r •!! cells means 

tion of the brain by means of nerves with the affection of 
whole anatomy of the body, and its sensitive- mm ' 
ness to all impressions of bodiiy disease, 
render its mental functions liable to disturb- 
ances, which may be slight and fleeting, or 
serious and more lasting. But, in addition, its 
own diseases or disorders depend largely on 
the bodily health, and add also to the risks of 
mental diseases. The laws of health should 
be carefully observed, not only in the interest 
of the body, but still more so of the mind, 
which is affected for good or evil by the bodily 


health. The nature of mental disorders, and 
how to manage them, are subjects of consider- 
ation so important as to require a chapter to 
themselves, and your attention will be specially 
called to them later on. 
Disorders of We have now to consider that reflex func- 
tions, tions may also be altered by disease. They 
may be quickened, as when the soles of the 
feet are easily tickled, when sneezing or vomit- 
ing is easily excited, or when teething or 
worms cause convulsions in a child. On the 
other hand, the reflex functions may be par- 
alyzed, as you see in the last stage of paralysis, 
where swallowing is difficult and there is risk 
of choking, where the patient becomes of wet 
and dirty habits, because of his inability to 
retain urine or stools, and where the feet do 
not respond to tickling. 
The special Our observation of the nervous system pro- 

senses or 

"gateways of ceeds one stage further, and there it ends. We 
have looked upon the nervous system as the 
groundwork of self-acting reflex functions, as 
the mainspring of muscular movements, as a 
medium of sensation, and as the organ of the 
mind. As a medium of sensation it contri- 
butes knowledge, and in this respect is a feeder 
of the mind ; but we have yet to reflect on 


other paths of sensation, which take a higher 
position as mind-feeders, and are most essen- 
tial to the growth and development of the 
mental functions. These are the special 
senses, popularly known as the gateways of 
knowledge. Their names are sight, hearing, 
taste, smell, and touch. 

The eyeball is the organ of sight, and pos- The sense of 
sesses its lenses, chambers, refracting media, 
muscles and nerves, all specially constructed 
and arranged for the purpose of bringing to a 
focus rays of light reflected from any object, 
which is thus photographed in the eye, and the 
result transmitted along a nerve to the brain. 
Thus pictures of all we see are photographed 
in the brain, so that the mind can think and 
act regarding them. A slight derangement in 
the apparatus, whether in the eye, the nerve, 
or the brain, disturbs the functions more or 
less seriously ; for, as with the other nervous 
functions, the whole line must be in good re- 

The ear is the organ of hearing, and its con- The sense of 

. . . , .. _ . ,, hearing. 

struction is extremely delicate, and specially 
designed for the collecting and conveying of 
sound-waves, and for the perception of the 
nature and direction of sounds. A special 


nerve passes from it to the brain, conveying 
the impressions found in the ear, and in this 
way the brain registers sounds, distinguishes 
their character, and determines the direction 
whence they come. The nature of the sounds 
varies with the volume of the sound-waves and 
the rapidity with which they succeed each 
other when striking upon the ear. 
The other The apparatus for taste, smell, and touch, is 
senses. the same as the preceding in general design, 
but the construction of the end organ is simpler, 
and it can only be seen under the microscope. 
The senses of taste and smell resemble each 
other in much the same way as do the senses 
of hearing and sight. Impressions of hearing 
and sight are produced by waves of sound and 
light, impressions of taste and smell by invisi- 
ble particles touching the end organ. The 
smell of a drug, for example, is excited by a 
delicate vapor, the particles of which touch 
upon and stimulate the end organ of smell. 
The sense of touch is communicated from all 
parts of the body, and has end organs of special 
and simple construction in the skin. These 
have their corresponding nerves, which all con- 
verge to the brain and conduct messages 


Each sense, then, has its own peculiar appa- The senses 

t . r r-« 1 • ar e observa- 

ratus and its respective function. Each is an t0 ries of the 
observatory for the brain ; and all combined 
contribute the sum of knowledge necessary for 
the full development and the proper exercise of 
the mind. When their functions are disordered 
so as to affect the mind, a serious form of in- 
sanity appears, and you will be told of it in the 
chapter on mental diseases. But we may here The heipiess- 

. ,. . ness of man 

consider how a mans mental condition is without 
affected not by disease, but by the absence of 
one or more senses. If a man is born blind, 
what can he know of color and expression ? if 
he is born deaf, what can he understand of 
sound or music? Without the senses, what 
can a man know or learn, or what communica- 
tion can he hold with other minds ? 

Yet there are surprising and gratifying in- The educa- 

r 1 i c • tion of re " 

stances or the loss or one or two senses stimu- maining 

senses to 

lating the patient to the better exercise of makeup for 
those which remain. The blind man finds a lost or wanS 
welcome compensation in the quickness of his mg * 
sense of touch, in the increasing acuteness of 
his sense of hearing, and in the new uses 
which he may find for the senses of taste and 
smell. One gateway of knowledge is closed; 
but he is no longer disconsolate, when he 


How much learns how much more helpful the others are 
?n n thfs way than they were before. In the wards of our 
Attendants, asylums there is no more encouraging feature 
in the experience of attendants than to see the 
idiot, born blind or deaf, increasing his knowl- 
edge, his pleasures and usefulness, and making 
the best of his small brain and few senses, 
under the painstaking care and judicious aid 
of those whose duty it is to lighten his burdens 
and brighten his existence. 




OST asylums contain wards set apart for Tne . care of 

. . . the infirm. 

the accommodation or patients in more 
than usually feeble bodily health. The sick 
and infirm persons in such wards naturally 
require more careful attention to their wants 
and symptoms than do those patients that 
enjoy comparatively good bodily health, and 
the wards and rooms in which they are placed 
also require to be kept even more than usually 
clean, orderly, and quiet. These wards must be 
looked on as most important, and the position 
of the attendants in charge of them is both 
difficult and honorable. 

All attendants should acquire, as soon as a knowledge 

1 m of sick-nurs- 

possible, some knowledge of sick-nursing, as ing necessary 

- . . , for an attend- 

any one of them is liable to be called on to ant. 

perform this special and important duty. 

In this section of the handbook a few plain 

directions are given to aid attendants in carry- 



ing out the orders of the medical officers re- 
garding the sick. 


Special care must be taken to keep those 
rooms in which patients are confined to bed in 
proper order. 

Ventilation. A full supply of fresh air is specially neces- 
sary in sick-rooms ; for the sick, on the one 
hand, destroy the air more rapidly than do 
those in health, and, on the other hand, an 
abundant supply of pure air is necessary to aid 

The causes recovery in many cases. The breath from 

of impure . ' . J . ,. , t 

air. patients suite ring from lung diseases, the dis- 

charges from sores, the unhealthy perspiration 
of the sick, and the odors arising, in spite of 
constant attention, from those of wet and dirty 
habits, all tend to make the air foul ; while 
specially pure air has to be supplied to those 
whose powers of circulation and of respiration 
are feeble, who are unable to stimulate these 
functions by exercise, and whose lungs may 
be, through disease, only partially available for 
their proper functions. 

How to keep The purity of the air is to be secured, in the 
ir pure. ^^ place, by the prevention, as far as pos- 
sible, of the causes of bad smells, by strictly 


attending to cleanliness, and the removing at 
once of all discharges, dressings, soiled linen, 
etc. ; and, in the second place, by the admis- 
sion of fresh air in proper quantity, by atten- 
tion to windows, doors, chimneys, and any 
special apparatus for ventilation that may be 

The windows may generally be kept partially The Win- 
opened. A number of windows opened a little 
is more useful and less draughty than one or 
two opened widely, and care must be taken in 
the opening of windows that no patient is ex- 
posed to direct draught. 

When there is a fire in the grate, a chimney chimney- 

flues 3.S VCIV* 

forms a very good ventilator, on account of the tilators. 
constant draught of air ascending it, as this 
draws a corresponding quantity of fresh air 
into the room to supply its place. When there 
is no fire in the grate, the damper with which 
most grates are provided should always be 
kept open ; a little soot falling from time to 
time shows that the chimney requires sweep- 
ing, but is no reason why ventilation through 
this channel is to be prevented by closing the 
flue. When special ventilators are provided, 
they should be carefully attended to. 

An equable temperature, generally between 


Tempera- jo an d 60 degrees, should be kept up in sick- 
rooms both by day and night. The thermome- 
ters on the walls should be frequently referred 
to, to ascertain that this is the case. In some 
diseases the keeping up of a special tempera- 
ture night and day is a matter of life or death 
to the patient. 

Light. in a sick-room the light should be subdued 

but cheerful. Sunshine should generally be 
allowed to enter freely, but not to stream on a 
patient's face and cause discomfort. The win- 
dow-blinds require constant attention, as the 
sun shifts its position. No more gas should 
be used than is required for proper s'perviss 
ion and attention to the wants of patients. 
It is to be remembered that burning gas 
rapidly consumes the life-giving properties of 
the atmosphere, and its glare is apt to induce 

Cleanliness, The greatest cleanliness is necessary in 
every nook and corner of a sick-room. The 
floors, etc., should be frequently cleaned. 
This should be done, however, with the use of 
as small a quantity of water as possible in 
those rooms where patients are confined to 
bed, for a damp floor is dangerous to those 
lying in bed above it. All stools, discharges, 


dressings, and soiled linen should be at once 
removed, and all plates, cups, medicine 
glasses, etc., kept clean and neatly arranged. 
It is not safe either for an attendant or for 
the sick to be dirty, the hands especially 
always being washed before and after dressing 
wounds, etc. 

Any one who has suffered from even so mild Q u *et. 
an ailment as a slight headache can appreciate 
the necessity of quiet in a sick-room. Loud 
talking, the wearing of heavy boots, clattering 
of plates, banging of doors, etc., are to be 

Much may be done by a good attendant to Cheerful- 
make a sick-room and its occupants cheerful, 
by attention to the little wants of the patients, 
by providing them with books and work when 
these are allowed, by talking with those in- 
clined to conversation, and by attention to 
flowers, to the neat serving of food, orderly 
arrangement of bed-clothes, etc. 



The meals of the sick should be carefully Food, etc 
and neatly served. A capricious appetite may 
be tempted by a neat morsel, served at the 


Medical right time that might reject a half cold and 

sanction nee- ° . 

essaryfor slovenly served dish. All extra diet must be 

the introduc- . 

tion of arti- strictly adhered to. No sick patient should be 

clesofdiet. . , . , . . , 

given anything to eat but what has medical 
sanction. In some diseases the life of a pa- 
tient may be seriously endangered by the 
administration of unsuitable food, given though 
it may be with a good-natured intention to 
humor or indulge him. 

Friends visiting the sick often bring in 
cakes, fruit, etc. Such articles should be at 
once taken in charge by the attendant, who 
should in no instance give them to the patient 
without permission. 

Sick persons, especially amongst the insane, 
are apt to refuse food, but, in many cases, by 
persuasion and patience, an attendant can suc- 
ceed in getting them to take it. Patients' 
tastes and fancies for or against various arti- 
cles of food should be observed and reported. 
Beds All beds should be frequently aired, and 

should be as thoroughly made as possible 
every day, but no patient suffering from seri- 
ous bodily disease should be raised for this 
purpose without special medical sanction. The 
bed-clothes should be neatly arranged, and 
kept drawn up near the chin .oi the patient, 


who should be discouraged from keeping his 
arms out, and chest bare, unless these are 
protected by a flannel jacket or other extra 
covering. Many of the insane are constantly The Bed- 
throwing off the bed-clothes. These require 
to be as frequently replaced. A patient lying 
half covered presents an appearance of neglect 
and slovenly management, besides being ex- 
posed to danger from risk of catching cold. 
Some margin may be allowed for the fancy of 
individual patients as regards the quantity of 
bed-clothing, but in no case is one to be al- 
lowed to become cold, an extra amount of bed- 
clothing being frequently required to keep the 
bodies of feeble sick persons properly warm. 
Cold feet are dangerous in all cases, and often Cold Feet, 
cause great restlessness and sleeplessness in 
old, feeble persons. When the feet are found 
to be cold, — and they should frequently be felt 
to ascertain this, — a properly protected hot- 
water vessel should be at once applied. 

The undersheet is to be kept perfectly The Under- 
smooth and scrupulously free from crumbs, etc. 
Wrinkles in the sheet, and crumbs lying on it, 
give rise to great discomfort, and frequently 
cause troublesome bed-sores. 

A piece of waterproof sheeting should be 

5 2 


The Water- placed next the mattress of all wet and dirtv 

proof Sheet. , J 

cases, in order to keep it clean. These sheets 
require frequent washing, and the mattress 
should be at once removed if it absorbs any 
discharge through the displacement of the 
waterproof sheet. 

As a rule, the sheets should be changed as 
often as they become wet or dirty, no matter 
how often this may occur. In some cases of 
paralysis or great weakness, the stools and 
urine are passed almost continuously, and the 
condition of the patient renders the fatigue to 
him of frequent changing undesirable. In 
such cases, the drawsheet is of great service. 
A drawsheet is a sheet folded several times 
lengthwise : one sheet, thus folded, is passed 
beneath the loins of the patient, and above 
the usual undersheet. As one portion be- 
comes soiled, a fresh portion is drawn gently 
beneath the patient, while the soiled portion 
is folded up at his side. One sheet may thus 
serve several occasions, but it should always 
be removed when it becomes so much soiled 
as to be offensive. Various forms of urinals 
are used to receive the urine of patients 
passing it unconsciously. These should be 
kept constantly in position, and are to be 

The Draw- 



frequently emptied, and kept scrupulously 

Waterbeds are frequently used. They should 
be filled with water somewhat below the tem- 
perature of the human body, as ascertained by 
thermometer, say 90 degrees. 

No patient may be taken out of bed and Cleansing of 

sick patients. 

placed in a bath without special orders. When 
a bath is given to a sick patient, great care 
must be taken that he is warmly clad while 
going to and from it, that he is not exposed to 
draughts, and that all linen, etc., is ready, 
aired, and warmed, so that no time may be 
lost in covering him again. Much may be 
done to keep the persons of patients lying in Sponging the 
bed clean, by careful sponging. One limb 
should be sponged at a time, then the front of 
the body, and then the back. Each part thus 
sponged should be carefully dried before a 
fresh part is commenced with. Great care 
must be taken that the bed-linen does not be- 
come damp in the process. The face may in 
all cases when there is no special disease of 
that part, such as erysipelas, be kept clean by 
tepid sponging. The eyelids require special 
attention to remove the matter that so fre- 
quently accumulates about them. In serious 


cases, the lips and mouth become dry and 
crusted. These crusts should be partly re- 
moved with a small stick covered at one end 
with soft lint and dipped in water. Special 
attention requires to be paid to keeping clean 
the private parts of paralytic patients. The 
hair of the sick is very liable to become in- 
fested by lice, and requires increased attention. 
The nails also grow fast, and require frequent 
The use of An attendant cannot be too careful about 
ante? f disinfectants, and should carry out the instruc- 
tions of the medical officers regarding their 
use to the very letter. They are frequently 
ordered in cases of infectious disease, and a 
neglect of their use cannot but cause danger 
to the attendants themselves as well as to all 
others in the institution. 
Keeping of In many cases of disease, charts are kept, 

Charts and . . . , . . r , 

Records. showing the condition ot the temperature, 
pulse, and respirations at certain times, and 
attendants should learn to fill in these accu- 
rately and neatly. Other papers also are kept 
in some cases, on which are recorded the tem- 
perature of the room at stated intervals, the 
amount of food, drink, and stimulants taken, 
and at what hours, the amount of sleep ob- 


tained, the frequency of stools, of fits, of 
paroxysms of coughing, etc. All entries on 
charts or records should be made at once, for 
experience shows that the best memory is not 
to be trusted on these points. 

Attendants in charge of the sick will find it Noting of 

# ° m Symptoms. 

useful to keep a private note-book in which 
to enter, between medical visits, any symp- 
toms or matters of interest occurring in the 
patients that do not require to be immediately 
reported. Such a book, carefully kept, will 
prevent the danger of any symptom being for- 
gotten, and in it may also conveniently be 
entered any fresh instructions regarding medi- 
cines, etc., given by the medical officers at 
each visit. 

Attendants should be able to report intelli- 
gently regarding the symptoms of the sick 
under their charge to the medical officers at 
their visits. 

Among the principal subjects on which in- 
formation may be asked, are the following : — 

Appetite, The amount of food taken. The 
mode of chewing and of swallowing. 

Bowels. How often moved, and at what 
times. Whether the stools are full or scanty, 
natural, costive, relaxed, watery, painful, bloody, 



of Urine. 


or of peculiar color or smell. Whether they 
contain foreign bodies sometimes swallowed 
by the insane, such as pebbles, buttons, etc. ; 
or contain worms, and of what kind the worms 
are, whether threadworms, roundworms, or 
tapeworms. Whether the patient is attentive 
to the calls of nature, or wholly or partially 
neglectful in this respect. 

Urine. How often passed, and in what 
quantity. Whether it is natural in color, or 
unusually pale or dark. Whether it is clear 
or turbid, or contains blood, or matter, or 
gravel. Whether it remains clear, or deposits 
a sediment on standing, and the color and 
quantity of this sediment. Whether it is 
passed easily, or with difficulty, or pain. Great 
attention should be paid to paralytic patients, 
and indeed to all who are seriously ill, and to 
those recently admitted, and it should be at 
once reported if they do not pass water for 
some length of time, appear wishful but unable 
to pass it, or pass it constantly in a feeble 
trickle ; all these conditions showing that 
there is something very serious amiss. 

Conditio?is peculiar to women. These condi- 
tions are to be the subject of frequent report 
by the nurses. 


Cough and Expectoration. The frequency of Expectora- 
the cough, and its character, whether slight or 
severe, dry, or accompanied by spit, etc. The 
character of the spit, whether clear or opaque, 
tinged with blood, or dark-colored. 

The spit, and all unnatural motions and dis- 
charges, should be preserved for inspection at 
each medical visit. 

Other important symptoms are vomiting, at- other im- 
tacks of shivering, bleeding at the nose, fits, Symptoms. 
attacks of faintness, etc. All these must be 

Pain. Any complaint of pain on the part of 
a patient should be noticed and reported, and, 
also, if a patient appears to shrink or complains 
of pain on any portion of the body being 
touched. All pressure on or interference with 
painful parts is to be avoided. 

Complaints of pain or peculiar sensations 
must also be reported. 

Sleep. How long, and at what times, whether sleep, 
peaceful or disturbed, whether light or pro- 
found. Unusually deep sleep with heavy 
breathing and a difficulty in arousing the 
patient may indicate a dangerous condition. 

Effect of medicines and stimulants. When 
medicines are given, the effect should be 


watched, especially in cases where sleeping- 
draughts have been administered. When stim- 
ulants are given, it should be noted whether 
they appear to soothe or excite, to increase or 
diminish strength, to cause drowsiness or wake- 
fulness, or be followed by flushing of the face. 
External appearances. All bruises, eruptions, 
sores, swellings, distortion of limbs, or other 
unusual external appearances, are to be re- 
ported, every opportunity being taken while 
patients are changing their clothes to see that 
all is right in these respects. 


Taking Tem- The normal temperature of the human body 

peratures. x J 

is 98.4 degrees. The temperature of a patient 
is usually taken by placing a thermometer in 
the armpit. The index of the thermometer 
should be gently shaken down to 95 degrees 
before each observation. It should then be 
placed close to the skin, with its bulb in the 
centre of the armpit, and the arm brought 
close to the side of the body. Care must be 
taken that the skin is dried, and that there is no 
clothing between it and the bulb. Ten minutes 
is usually long enough to leave the thermometer 
in, if the patient has been well covered up 


beforehand. If not, he should be well clothed 
up to the chin for ten or fifteen minutes before 
it is inserted. 

Temperatures are sometimes taken in the 
mouth, but attendants should never attempt to 
do this in the case of insane patients. 

The average rate of the pulse is 70 to 75 Feeling the 
beats a minute. Feeling the pulse is per- 
formed by placing the first three fingers of the 
right hand on the patient's wrist, on its inner 
margin, just a little above the thumb. The 
pulse may be slow or fast, strong or feeble, 
regular or irregular, or intermittent. An at- 
tendant should be able to count the number 
of beats a minute of a pulse, and be prepared 
to report roughly on its character, but a 
proper appreciation of its character can only 
be made by a medical man. 

As a rule an adult breathes about 17 times Counting 
a minute. The respirations are counted bytions. 
watching the movements of the chest — each 
rise and fall making together one respiration. 
This can generally be done without moving 
the patient's clothes. While counting it may 
be noted whether the breathing be regular or 
irregular, light or heavy, easy or painful, etc. 

Cold dressings are applied to wounds or 


CoidDrass- sores, and are usually lotions or ointments, 
or of plain water. They should be changed 
regularly, and should always be replaced or 
renewed when removed or destroyed by a 
restless patient. The old dressing should 
never be taken off until the new one is ready 
to be put on. Dressings are to be removed 
gently, from both sides of the wound or sore at 
once, drawing them off towards the centre. The 
edges of the wounds and sores should be gent- 
ly cleansed, but the surface should never be 
touched except with such applications as may 
be specially ordered. Any alterations in the 
appearance of the sores should be noted when 
the dressings are changed. Everything re- 
quired for a dressing must be in readiness 
before the operation is commenced. The old 
dressing should be removed at once from the 
sick-room and burned. 

Wet compresses. These consist of a roll of 
flannel or calico wrung out of cold water, ap- 
plied to the part, and covered with waterproof. 
Wet compresses should be allowed to remain 
on continuously, and should not be renewed 
unless they become dry. 

Poultices. Poultices may be of bread, linseed meal, 

mustard, etc. Mustard poultices, though so 


named, are rather of the nature of a blister, 
and care must be taken not to let them re- 
main on too long, for a nasty sore may be the 
result. Other poultices proper should be ap- 
plied as warm as can be borne, and should be 
frequently changed. A poultice applied all 
round the chest is called a jacket poultice. 
Jacket poultices require frequent changing, 
the skin being gently wiped dry before each 
fresh one is put on. A cold jacket poultice is 
worse than useless, from the chill it may 
cause about the diseased organs. 

Fomentations are made by wringing flannels Fomenta- 
out of water as hot as can be borne. They 
should be applied to the skin at the part di- 
rected, and covered with waterproof to keep 
the heat from being lost by evaporation. 
They should not be allowed to get cold, but 
be renewed frequently during the time their 
application is directed. A material called 
spongio-piline is frequently used for fomenta- 
tions. It is a thick woollen material, with a 
waterproof coating on one side. The hot 
water should be applied to the woollen side. 

Stupes are fomentations with some external stupes, 
remedy, such as spirits of turpentine, poured on 
the surface that is to be placed next the skin. 


Enemas. When an enema is given, of whatever kind, 

whether of food, medicine, or purgative mix- 
tures, etc., the amount ordered must be strictly 
adhered to. When a warm enema is admin- 
istered, care must be taken that it is not too 
hot, not more than 90 degrees. The tube is 
to be oiled, and passed gently in a backward 
direction for two or three inches into the 
bowel with the right hand, while the patient 
lies on the left side, with the knees drawn up. 
The injection should be very slowly and most 
gently administered, and its flow should be 
stopped at once if the patient shows any sign 
of distress. When the required quantity has 
been injected, the tube is to be gradually and 
gently withdrawn, and the buttocks pressed 
together for a few minutes. Air must not be 
injected, and for this reason the syringe 
should be filled before the introduction of 
the nozzle. 

Great care must be taken in using all warm 
applications, whether poultices, fomentations, 
or stupes, that they are not too hot, and the 
same caution is necessary in the case of 
enemas, and of food, etc., given by the mouth. 

Supposi- Suppositories should be gently passed up 

the bowel with the forefinger of the right hand 


for a distance of two inches, while the patient 
lies on the left side, with the knees drawn up. 
A little sweet oil on the suppository and on 
the finger facilitates the operation. Care 
should be taken to ascertain that a supposi- 
tory is retained in the bowel. 

Great difficulty is frequently experienced in Gargles, 
teaching patients to gargle properly. An at- 
tendant may learn to do it himself, and thus 
teach them by gargling in their presence, and 
explaining how it is done. A patient should 
always sit fairly up in bed before being allowed 
to gargle. 

When steaming is ordered, care is necessary steaming 

. . i«i an d Inhala- 

to see that the steam constantly strikes on the tions. 
nose and mouth of the patient, and that the 
steam is not too hot at that point. The moist- 
ure gathering on the face should be wiped off 
from time to time, and the pillow and upper 
part of the body and bed-clothes protected 
from the moisture by waterproof sheeting. 
When steaming is ordered, it must be con- 
stantly kept up for the time directed ; other- 
wise it may do more harm than good. 

Hot, tepid, and cold baths may be ordered Baths » 
medicinally. The temperature ordered must 
be strictly maintained during the whole time 


the patient is in the bath. To ascertain this, 
a thermometer should be in constant use. 
Should any symptom of faintness come on 
while a patient is in a bath, he should be at 
once removed and placed in bed. 

The Wet Packing in the wet sheet is thus performed : 

■ — The patient is to be stripped, and the whole 
of his body wrapped in a sheet wrung out of 
water, which may be hot, tepid, or cold, ac- 
cording as may be ordered. He is then en- 
veloped in a blanket, and laid on his side, in 
bed, on several thicknesses of blanket. A 
number of blankets are then placed over him, 
and carefully tucked in all round him and up 
to his chin. A patient in the wet pack is not 
to be left on any account, but must be care- 
fully watched during the time he is in it. 
When the time ordered has expired, the wet 
sheet is to be removed, and the patient's body 
rapidly sponged with tepid water and dried. 
He is then to be placed in a well warmed bed, 
and carefully covered up. 

Sponging. Cold or tepid sponging is sometimes ordered 

in cases of fever, etc. It is to be done while a 
patient is in bed protected by waterproof 
sheeting. As the cooling effect is desired in 
such cases, the body of the patient should be 


exposed during the time the sponging is or- 
dered to be continued. Should any symptom 
of faintness come on, the patient should be 
at once dried, and removed to a warm bed. 

All medicines must be given regularly at the Administra- 

fe . . ^ J tionofMed- 

times and in the quantities ordered. It is cmes. 
well to shake all mixture-bottles before pour- 
ing out the required dose, even if this direc- 
tion is not specially given on the label. The 
label of directions must be read each time be- 
fore the medicine is given, and the quantity 
ordered carefully measured into a clean glass. 
In giving pills care must be taken to see that 
they are really swallowed by a patient. Should 
any patient refuse medicine, this fact should 
be carefully reported. 

When a patient refuses food, much may be Forcible 


done by attendants by means of gentle persua- 
sion with some, and by a firm but kind man- 
ner with others. Beyond this, an attendant 
should never go. No apparatus for forcible 
feeding may be employed by any other than a 
medical officer under any pretext whatever. 

Great care is necessary in feeding para- 
lytics, delirious patients, and those who are 
unconscious or dying. The quantity given at 
a time should be very small, and it must be 



ascertained that one spoonful has been swal- 
lowed before another is placed in the mouth. 
No paralytic or epileptic patient should eat 
Bandaging. Of bandaging, little can be learned from a 
book. In bandaging a limb, the bandage 
should be carried with a gradually decreasing 
pressure from below upwards. Any complaint 
or appearance of a bandage being too tight 
should be at once attended to, and the band- 
age loosened without loss of time. 




In any case of faintness, the patient should 
at once be placed on his back, the clothing 
about the neck should be loosened and the 
chest bared, while fresh air is freely admitted. 
The face and chest should then be flicked with 
the end of a towel dipped in cold water, while 
warmth is applied to the feet and limbs by 
means of hot-water vessels and heated flan- 

When a patient takes a fit, he should be 
laid on his back on a bed or sofa, or, if nei- 
ther of these is at hand, on a clear space on 
the floor. A pillow is to be placed under his 
head, and the clothing about the neck and 


chest loosened. In violent convulsions the 
movements may be gently restrained, care 
being taken that the patient does not in- 
jure himself by dashing his head or limbs 
against the floor, the walls, or the furniture. 
Some patients show warning signs of an ap- 
proaching fit of epilepsy ; and when these oc- 
cur, he should be induced to lie down as soon 
as possible, and remain lying until the fit is 
over. In nearly all cases of epilepsy, a period 
of rest in the recumbent position after the. fit, 
to encourage sleep, is desirable, and may ward 
off the excitement that frequently follows. The 
character and duration of a fit should be ob- 
served, and notice taken which parts of the 
body are most affected by convulsions. If a 
fit occur in a patient not known to be epileptic, 
and, in the case of those subject to fits, if the 
attack be unusually long or severe, medical 
aid should be summoned. > 

Should apoplexy, or any other form of loss Apoplexy. 
of consciousness by a patient, occur, the cloth- 
ing about the neck and chest is to be loosened, 
the patient placed in bed, and a medical officer 
sent for without delay. 

Should choking occur, medical aid must be Choking, 
instantly summoned, as every moment is of the 


greatest value. Paralytics, epileptics, dying 
persons, and those of the insane addicted to 
" bolting " their food, as also suicidal patients, 
who sometimes seek self-destruction by this 
means, require to be specially watched and 
guarded against choking. 

Until aid comes, all food should be removed 
from the mouth, the body of the patient in- 
clined forwards, and his back be sharply 
clapped with the back of the hand. 
Hemorrhage Any considerable loss of blood is at once to 

or Bleeding. 

be reported, the color of the blood and the 
quantity lost being carefully noted. In the 
case of bleeding from wounds and incisions, 
the flow of blood may be controlled somewhat 
until medical aid arrives, by pressure on the 
spot with the finger or a pad of linen, and by 
the application of cold water allowed to drip 
on the part from a sponge. The part from 
which the blood comes should be raised as 
much as possible above the rest of the body. 
In bleeding from the nose, the head should be 
kept erect, and the hands raised above it. 
Labor. No nurse that has not received special in- 

struction in midwifery should attempt to inter- 
fere with a patient in labor, but should place 
her in bed, and at once report the case. At- 


tendants on the insane must, however, care- 
fully watch patients that are pregnant, as the 
insane in this condition frequently give no 
warning of the onset of labor by expressing 
their sufferings, or even by showing signs of 

One of the most common modes of suicide Attempted 


attempted by insane patients is hanging or 
strangulation. In some of these cases, the 
life of the patient may be saved by prompt 
and timely action on the part of an attendant. 
The moment such a case is discovered, the 
ligature should be at once cut and removed Hanging or 

r * i -rr i \ • • Strangula- 

from the neck. If tne patient is unconscious, tion. what 
means are to be taken to restore him by the 
application of cold water as in cases of faint- 
ing; and if the breathing has ceased or is 
feeble, artificial respiration is to be instantly 
commenced, and continued until medical aid 

Artificial respiration is performed thus : The Artificial 

, . , i'ii Respiration. 

patient is laid on his back, and the operator, How it is ac- 

,. i'ii 1 • 1 complished. 

standing at his head, grasps the patient s 
arms, just above the elbows, draws them 
gradually upwards till they meet above the 
head, and keeps them in that position for two 
seconds ; then, bringing the arms down again, 


he presses them gently but firmly against the 
sides of the chest for two seconds more. These 
acts are to be steadily repeated alternately, and 
the process of artificial respiration by this 
means continued until medical aid arrives. 
Hints in case When poisons have been taken, vomiting 

of poisoning. 

may be encouraged by tickling the throat, and 
by the administration of warm water with a 
little mustard added to it. 


Nothing is a surer test that careful attention 
is given by the attendants to the sick-nursing 
in an asylum than the absence of bed-sores in 
those patients liable to them, and the success- 
ful management of such sores, when, in spite 
of every precaution, they do unfortunately oc- 

The patients most liable to bed-sores are 
those known in asylums as general paralytics, 
those suffering from other forms of paralysis, 
and those that, confined to bed for a length- 
ened period, have become extremely feeble and 
emaciated. Such cases require very special 
attention to the state of their skin and the 
bedding on which they lie. The undersheet 
should be kept smooth, free from crumbs, and 


as dry and clean as possible, and the position 
in which the patient lies should be frequently 
altered. The back should be examined daily 
and carefully cleaned, and a liniment, when 
such is provided for the purpose, regularly 

When bed-sores occur, they are to be man- 
aged as are other such wounds, but with an 
extra amount of care as to cleanliness, and 
with frequent change of dressings, which, from 
their situation, are apt soon to become foul. 



When a patient dies, the eyelids are to be The Dead, 
closed by gentle pressure with- the fingers, and 
a bandage applied under the lower jaw to 
support it. The limbs are to be straightened 
out, the arms placed by the sides, and the 
lower extremities kept in position by a bandage 
round the ankles, and by one connecting the 
great toes. The clothing is then to be re- 
moved, the body thoroughly washed, and re- 
clothed in a clean bed-gown. The corpse is 
then to be completely wrapped in a clean 


Brain the 
organ of 


AS already shown in a former section of the 
Manual, the brain is the centre of the 
nervous system. In it all the nerves of the 
body converge ; and through them it regulates 
the movement, sensations, and nourishment of 
every part of the body. But the brain has 
still another function — it is the organ of mind. 
A healthy mind requires a healthy brain ; and 
all disordered mental manifestations have their 
origin in derangements of the brain. 

The mind is complex in its constitution ; and 
we are still very far from having a complete 
understanding of it, or an accurate knowledge 
of its working. But for our purpose it is suffi- 
cient to regard it as being made up of (i) the 
intellectual faculties, (2) the will, and (3) the 
emotions or feelings, 
intellectual The intellectual faculties are the reasoning 

or Reasoning . , . . , , 

Powers. powers, those powers by which we observe or 
perceive, judge of and compare, and reason 




regarding our surroundings or anything put 
before us, and in them we include also memory, 
the power of recalling to our mind former 
events or impressions. It is these faculties 
which we appraise roughly when we speak, in 
ordinary language, of a person as being of good 
intelligence or the reverse ; and in health they 
are not only up to the normal standard in 
power, but are also always more or less actively 
in use. 

The will is the faculty by which we direct The : will, 

J J . Feelings and 

and control our actions. Certain desires and instincts, 
susceptibilities are, as observation shows us, 
implanted in every person independently of 
the reasoning powers, such as the love of life, 
the love of offspring, the capacity for joy and 
grief, etc.; and these are termed the emotions 
or feelings. In addition to the purely mental 
faculties, we also have various " organic " or 
bodily appetites or desires, such as the appetite 
for food and drink, and the sexual instinct ; 
and these are called the organic appetites or 

By insanity is meant " disease or unsound- Unsound 

r ■• i is is- i i Mind - 

ness of mind ; and this unsoundness shows 

itself in a derangement or alteration of one or 

more of the mental faculties, feelings, or in- 


stincts. Thus the intellectual or reasoning 

powers may be more or less impaired in their 

working, or may be so perverted that the 

Affections of person forms notions which are altogether 

the reason- . 

ing powers, wrong and constitute delusions ; or the will 

the will, the , _ . r . . rr . 

feelings and and power 01 self-control may be affected ; or 
petites? ap " the feelings and organic appetites are dis- 
ordered. The outcome of this mental derange- 
ment is seen in the patient's conversation and 
general conduct. For instance, when a person 
who is naturally bright, active, and cheerful, 
becomes dull, stupid, and unable to do his work 
properly, or says that he is Jesus Christ, or 
feels intensely miserable without due reason, 
or shows by his conduct that he is acting 
from motives which are not usually recognized 
as natural and reasonable, we say that he is 
insane. The mental condition of every person 
varies from time to time under different circum- 
Uuheaithy stances ; but such variations are not regarded 

variations in 

the Mental as unhealthy so long as they do not pass be- 

Condition. . ,. .- -^ . . . . 

yond certain limits. .But when the variations 
are such as to render the person unable to 
take proper care of himself, or to behave 
rationally towards his fellow-creatures, they 
are regarded as morbid, and the mental condi- 
tion is considered unsound. 


A person's mental state is judged of by (i) Mental 

x • otcltG IS 

his conversation, and (2) his conduct; and m judged by 


estimating these we compare him with the and conduct, 
generality of his fellow-men. We also compare 
him with himself as he was before becoming 
insane. Even before speaking to him, we 
may learn much regarding him by noting his 
expression, posture, etc. We see whether he 
is bright, lively, restless, and energetic, or dull, 
stupid, and listless, or suspicious of those 
around him. Then in conversation we find 
if he has a proper understanding of what is 
said to him, if he answers correctly and intelli- 
gently, if his memory is good or bad, and if he 
has any delusions. And by more prolonged 
observation of his general conduct, we judge 
if he shows any evidences of insanity in his 
actions or habits. 

In the great bulk of our cases, the intellect- insanity 

,. , .,. ,, r -i • i usually 

ual faculties, the will, and the feelings and affects the 

., , rr i Mind as 

organic appetites,, are all more or less anected a whole, 
together ; and it is rare to find one of them 
deranged without the others being also in- 
volved. Therefore, in shortly reviewing the 
symptoms of insanity, we take, first, conditions 
of disturbance of the mind as a whole. In con- 
sidering these, the changes in the intellectual 

7 6 


ment of 

Mental De- 

faculties are the most striking, and call for 
most notice, though the will and the feelings 
are also affected. Some further reference will 
then be made to the condition of the will, to 
the more common changes in the feelings and 
instincts, and to various insane acts and habits 
shown by our patients in consequence of their 
mental derangement. 

Our arrangement then is the following : — 

(A.) States of General Mental Disturbance, 
i. Depression of Mind. 

2. Exaltation of Mind. 

3. Enfeeblement of Mind. 

4. Perversion of Mind. 
(B.) Condition of the Will. 

(C.) Changes in the Feelings and Instincts. 
(D. ) Insane Habits and Peculiarities. 

(A.) States of General Mental Disturbance, 
(1) Depressiofi of Mind. In this condition 
there is a morbid feeling of distress or unhappi- 
ness. This feeling varies much in degree in 
different cases, being sometimes slight, at other 
times very intense and all-absorbing ; and it 
may also vary in the same case at different 
times. It may exist without any impairment 
of the intelligence — the patient may be able 
to converse rationally and acutely on the vari- 


ous subjects put before him, and show no 
evident mental weakness apart from the mor- 
bid feeling of wretchedness. But far more 
commonly the feeling of distress is more or 
less constant, and is so marked as to occupy 
the patient's thoughts more or less persistently, 
and interfere with the healthy play of the 
intellectual powers ; or there is very frequently 
great perversion of the intelligence, and delu- 
sions are developed. These delusions are of Distressing 

. , . . , Delusions. 

a more or less distressing nature, such as that 
poison is put in the food, that everybody is 
conspiring to kill the patient, etc. Often they 
have reference to the religious sentiment, such 
as that the patient has been cast off by God, 
and is doomed to eternal misery ; or to the 
bodily health, as when the patient says that 
his bowels are closed up, or that his stomach 
cannot digest the food he puts into it. 

In this state of mental depression, the pa- 
tient is sometimes very quiet, sitting quite still 
in his own place, disinclined to talk, or refusing 
to say even a single word, showing no interest 
in the persons and things around him, moody 
and self-absorbed, and brooding constantly 
over his morbid fancies. In other cases there 
is more or less restlessness, with talkativeness, 


crying and moaning, wringing of the hands, 
frequent complainings, and the other outward 
signs of mental distress. The mental depres- 
sion leads often to refusal of food, and to 
suicidal and homicidal acts by the patient. 
Mental (2) Exaltation of Mind. The intellectual 

Exaltation, -. .-, , -, . jA , 

powers, while not weakened in themselves, 
may be working at too high pressure, and the 
balance between them and the power of self- 
control be disturbed. The thinking centres 
in the brain are morbidly active, ideas pass 
through the mind with excessive rapidity, and 
the patient is more or less " excited " in his 
conversation and conduct. The power of self- 
control being now insufficient, the patient is 
absurd and extravagant in his behavior, talking 
too much, or chattering incessantly, wandering 
from one subject to another without apparent 
connection, and being restless, noisy, interfer- 
ing, impulsive, mischievous, destructive, or vio- 
lent. The degree of this disturbance varies 
very much in different cases. In acute delirious 
mania, for example, the brain excitement is so 
great that the patient is quite oblivious to 
ordinary external impressions, and he then 
remembers nothing of what happens during 
his illness. Or, without being delirious, he 


may evidently understand what is said to him, 
but be so excited that he cannot pay any 
steady heed to it (ordinary acute mania). Or, 
in the less severe forms of mania, he may 
understand and answer questions readily and 
smartly, but still show the mental exaltation 
in being excessively talkative and restless and 
interfering. The feelings and appetites are 
altered, and often exaggerated. 

(3) Enfeebletnent of Mind. The whole men- Mental 

, , , . . ! Enfeeble- 

tal power may be more or less impaired or me nt. 
destroyed. Intellectually, this is shown in 
stupidity, impairment or loss of memory, in- 
coherence, want of energy, want of attention, 
etc. The will power is weak ; and the feelings 
and instincts are usually much dulled. It is 
well seen in the condition of mental enfeeble- 
ment which often supervenes when the acute 
or severe symptoms of an attack of insanity 
pass off without recovery taking place. In 
degree it may vary from slight enfeeblement, 
indicated by some silliness or childishness in 
conversation or conduct, up to deep dementia, 
when the patient even cannot tell his own 

(4) Perversion of Mind. The intellectual Mental Per- 
faculties, with or without marked depression, De?usk>n. r 


exaltation, or enfeeblement, may be so twisted 
in their action that the patient forms a wrong 
conception regarding himself or his surround- 
ings ; and he is then said to show delusion. 

A delusion is a " false belief arising from 
diseased mental action.' 7 Frequently the be- 
lief is on the face of it preposterous and ab- 
surd, as when a person says that he is God 
Almighty and can move the world. At other 
times the patient's statement is not absurd in 
itself, as when he says that he has lost all his 
money, or that he is about to die ; and in such 
a case we have to ascertain that the belief is 
not founded on fact, or is not justified by the 
patient's circumstances, before regarding it as 
a delusion. 
Haiiucina- When the false belief refers to any of the 
special senses, of seeing, hearing, taste, smell, 
and touch, it is usually spoken of as a halluci- 
nation ; while those false beliefs which are not 
connected with any of the special senses, but 
are simply false intellectual ideas, are delu- 
sions proper. 
Examples of For example, a patient may say that at 
tions? Cma " night, when everything is quiet, he hears peo- 
ple in the next room or outside the house call- 
ing him by abusive names, and telling him to 


do things which he ought not to do ; he is 
then suffering from hallucination of hearing. 
In such a case there may be either no sound 
at all to set up the sensation of hearing ; or 
there may be some sound, such as the noise of 
the wind, which the patient hears, but mis- 
interprets and twists into some diseased no- Examples of 

<->,. .* i 'liti • • r «i Hallucina- 

tion. Similarly with hallucinations of sight : tions. 

a patient may say that he sees certain people 
in his room, when there is no one there at all ; 
or, seeing certain persons there, his sight per- 
ceptions regarding them are disordered, and 
he takes them to be other than what they 
really are. An example of hallucination of 
taste is when a patient says that he tastes the 
poison or filth which is maliciously mixed with 
his food; of hallucination of smell, when he 
complains of sulphur being burnt under his 
nose, or of bad smelling gases being led into 
his room ; and of hallucination of touch, when 
he imagines that insects are creeping all over 
him. # 

* When the false perception arises from something 
external, which really exists, but is misinterpreted, the , 
term illusion is sometimes applied to it. The term hal- 
lucination would then be restricted to that graver form 
of derangement in which there is a false sense-percep- 
tion with nothing external to account for it. A person 


Allied to the hallucinations of special sense 
are the cases of misinterpretation of those 
sensations which are perceived by us as aris- 
ing in one or other of the organs in the body. 
For instance, a person after a severe drinking 
bout may misinterpret the pain felt in the 
stomach, and may think that rats are gnawing 
inside him. Similarly some patients say that 
their " inwards" are being constantly dragged 
on and twisted, 
importance Hallucinations are a very important symp- 

ofHallucina- ... „ , /- rr 

tions. torn in insanity. All the different forms may 

occur in cases of acute and recent insanity ; 
but the most frequent are those of hearing and 

hearing the noise of the wind, and taking it to be a 
voice, would be said to have an illusion of hearing ; 
while if he heard a voice when there was no sound at all, 
it would be a hallucination. 

A sane person may have illusions and hallucinations. 
Some people, for example, see the figures of animals, 
such as a cat, in the room, when there is really no ani- 
mal present. But the reasoning powers are brought 
into play to correct the false impression ; the person 
knows from other observations that there is no ani- 
mal in the room, and understands that it is simply 
his sight which is playing him false. When the false 
sense-perception is not corrected by the reasoning 
powers, but is accepted as true, it becomes a " false 
belief " and is delusional. 


sight. Often the hallucinations persist for a 
time, and then gradually pass away as the pa- 
tient progresses towards recovery. It is usu- 
ally an unfavorable sign if the hallucinations 
persist without change for more than five or 
six months, and often means that the patient 
will not recover. In the chronic forms of in- 
sanity the hallucinations most frequently found 
are those of hearing ; and every asylum shows 
cases in which the hallucinations of hearing 
constitute the most striking feature, and in 
which the patient's conduct is largely guided 
by what the " voices " tell him. Hallucinations 
of sight are common in the insanity associated 
with epilepsy. Occasionally hallucinations have 
their origin in some local disease of the organ 
of the affected sense ; and this ought to be 
kept in mind, for then the local disease should 
be corrected if possible. 

Delusions proper. These are found in very Delusions 

r • • , t r . i , proper : their 

many cases or insanity, and are of the most variety, 
varied character. Thus, in the depressed 
cases, the delusions are, as already mentioned, 
usually of a more or less distressing character, 
such as having committed unpardonable sin, 
being lost eternally, being repulsive to every- 
body, causing infection, and bringing evil on 


relatives, and having lost all property. In 
states of mental exaltation the patient may say 
that he is possessed of great wealth, that he is 
Jesus Christ, or Napoleon Buonaparte, or some 
person other than himself (delusion of iden- 
tity), that his legs are made of glass, etc., etc. 
These delusional ideas may be constantly 
changing ; or they may persist for some time 
and then disappear as the patient improves in 
his mental state ; or they may become perma- 
Limited or In some cases we find that the patient labors 

fixed Delu- 1 

sions. under delusions on one subject, or one set of 

subjects only, while apart from these particu- 
lar delusions he appears to be rational and in- 
telligent and can behave himself very well. 
This is the class known as monomania or par- 
tial insanity ; and here the delusion is more or 
less permanent or "fixed." In it we find the 
following three types of delusion: First, the 
monomania of grandeur or pride, as when the 
patient believes himself to be an emperor or 
king, the heir to the throne, or to be pos- 
sessed of great wealth or of the whole place 
round him. Second, some patients are mor- 
bidly suspicious, saying that they are the ob- 
jects of persecution, that they are constantly 


being insulted, and that every little thing that 
is done is intended to annoy them : they at- 
tribute their supposed injuries to the people 
around them, and often bring unfounded com- 
plaints against the attendants- and other pa- 
tients. These are the cases of monomania of 
suspicion. Third, another class carry these 
suspicious ideas to a still further extreme, and 
imagine that they are worked upon by elec- 
tricity, or mesmerism, or gases, but refer their 
persecution not to the real persons around 
them but to some imaginary, supernatural, and 
unseen power. This is termed the monomania 
of unseen agency. 

Delusions of different characters may be Varying 
shown by the same patient. Thus delusions the salnT m 
of grandeur and of suspicion may be associ- Patient * 
ated, as when a person says he is the rightful 
owner of certain property, but is unjustly kept 
out of it by the plots of his enemies. And de- 
lusions of a depressed character are sometimes 
found existing along with those of an exalted 
nature. It is of great importance to ascertain 
the particular delusions and hallucinations of 
each patient, as in them we often find the ex- 
planation of the patient's general conduct ; 
and from their character we are enabled to 


judge better of the patient's mental condition 
and of his propensities. For instance, a pa- 
tient may think that he hears a voice from 
heaven telling him to do away with himself ; 
and in such a case we must be prepared to 
guard against a suicidal attempt, especially if 
we see that the patient is very strongly under 
the influence of the hallucination. As with 
hallucinations, so with delusions proper : it is 
a bad omen when the false belief becomes 
fixed, while we are more hopeful as long as 
the delusions are of a changing nature. 
(£.) Condition of the Will. 
Condition of In health the will and the power of self-con- 

the will in , , , , , . 

insanity; trol regulate our general conduct, and keep 
pulses. m " our natural impulses within normal bounds. 
The strength of this self-controlling power 
varies greatly in different individuals, and is 
much influenced by the education and training 
which the person has received. Some persons 
seem to be naturally deficient in it — they are 
of "weak will," flighty and irregular in their 
conduct, and largely under the sway of their 
impulses. Or, on the other hand, the will may 
not be weak in itself ; but the impulses or de- 
sires may, either from vicious indulgence or 
from disease, be greatly intensified until they 


become overmastering in their strength, and 
the controlling power is now insufficient to 
regulate them. For example, persistent ex- 
cessive indulgence in alcohol begets a con- 
stant craving for stimulants, and at the same 
time weakens the will power which ought to 
enable one to control the craving ; and the 
person, from vicious indulgence of the habit, 
becomes a slave to drunkenness. But some- 
times drunkenness is a real disease (dipso- 
mania), not a vice ; the person is free from 
the craving for long periods together, but at 
certain times the desire for alcohol assails him 
with such terrible force as to be quite uncon- 
trollable, and he will then do anything in 
order to gratify the diseased appetite. Such 
diseased and overmastering impulses some- 
times hurry the patient on to deeds that he 
would naturally shrink from and abhor. 

In insanity the will and the power of self- The insane 

, r , . - . are not fully 

control are otten impaired to a greater or less responsible 

, . ', " r , t . for their ac- 

extent ; and there are frequently great irrita- tions. 
bility and impulsiveness. Then the insane 
often act under the influence of delusions, of 
ideas which are mistaken but which are never- 
theless very real to the patient ; and conduct 
which would be regarded as quite unnatural in' 



in Feelings 
and In- 
stincts ; ex- 

a sane person, may in an insane person be the 
very natural outcome of his diseased mental 
condition. Hence we should always bear in 
mind that the insane are not fully responsible 
for their actions, and sometimes are quite ir- 

(C.) Changes in the Feelings and Instincts. 

Any of the natural feelings, emotions, or 
appetites may be exaggerated, impaired or de- 
stroyed, or perverted. A few examples will 
best show what is here meant. There is natu- 
rally in every man the love of life, with a de- 
sire to preserve it. In some forms of insanity 
this natural feeling is destroyed — the patient 
has no wish to live, or may even loathe life 
and try to kill himself. In the mental de- 
rangement which sometimes follows child- 
birth, the natural affection of the mother for 
her child is often lost, or replaced by a feeling 
of intense hatred, and she may attempt to de- 
stroy the child. The appetite for food may 
be lost, and the patient refuse his food ; or it 
may be perverted, as when the patient eats 
filth and other repulsive substances. The 
sexual instinct may be lost, or it may be 
exaggerated and perverted, and then the 
patient gratifies his desires in an immode- 


rate or unnatural way, and shows indecent 

There is in health a feeling of bodily well- 
being or pleasure, which is often not appreci- 
ated during health, but the want of which is 
at once indicated when we say that we " feel 
unwell." This is often impaired in insanity, 
as when a melancholic patient says that he 
feels utterly miserable or wretched. Patients 
sometimes say that they have " no natural 
feeling." Or, on the other hand, the feeling 
may be exaggerated. In general paralysis the 
patient often says that he is thoroughly well 
and strong and in the very best of health, 
when in reality he is so paralyzed that he can 
hardly move or speak. 

(X>.) Insane Habits and Peculiarities. insane Acts 

™ u • , , . . r and Habits; 

lne various insane acts and habits of our examples, 
patients have their explanation in one or 
other of the forms of mental disturbance 
which we have just considered. Some of 
these acts have been already incidentally men- 
tioned. Wet and dirty habits, when not due 
to bodily paralysis, may arise from carelessness 
or wilful design, as in some cases of mania, or 
may be an indication of general mental en- 
feeblement, showing that the patient is too 


stupid to take care of himself. Destructive 
propensities, such as tearing clothes, are very 
common among the insane, and may be the 
result of a paroxysm of acute excitement, of 
Examples of mischievous intent, or of delusion. Fantastic 

Insane Acts 

and Habits, dressing, such as wearing a tinsel crown, is 
usually due to some delusion of grandeur. 
Theft is a frequent practice — the patient 
sometimes thinking that everything he sees is 
properly his, while at other times he is not 
able to control his morbid desire to get pos- 
session of whatever takes his fancy, even 
though he knows it does not belong to him. 
Under the delusion that stones, pieces of glass, 
etc., are articles of great value, patients may 
hoard up all sorts of useless rubbish, as often 
seen in general paralysis. Or they may squan- 
der their property recklessly, under the idea 
that their wealth is inexhaustible. Refusal of 
food may be due to loss of the natural appe- 
tite for it, or may be the result of a melan- 
cholic delusion such as that the food is 
poisoned, or that it cannot be paid for; or 
of an exalted delusion, as when the patient 
imagines he is a deity and needs no food. 
Talking to himself, especially in a loud 
scolding tone, usually means that the pa- 


tient hears or sees imaginary persons whom 
he is addressing. 

Other acts which may be evidence of in- 
sanity are stripping naked ; indecent exposure 
of the person ; sexual malpractices ; eating 
ravenously or like an animal, or eating strange 
articles ; and various other less frequent ec- 
centricities of conduct. But two propensities 
— the suicidal and the homicidal — require to 
be considered in more detail. A very large 
proportion of the insane are prone to injure 
themselves or others, and we have constantly 
to take measures for preventing suicidal and 
homicidal acts. 

Suicidal Acts. The suicidal desire may be Suicide 
due to simple misery or weariness of life. 
Such patients converse quite intelligently, be- 
tray no delusion, but say just that they are 
wretched and that life is a burden to them. 
These are cases which require most careful 
watching, for suicide is often attempted by 
them, and their mental acuteness makes them 
more able to elude the care of their guardians. 
More frequently, however, the suicidal pro- 
pensity springs from a delusion, as when the 
patient thinks that he is hunted by his ene- 
mies, or has some other distressing idea, and 

9 2 


The quiet 
cases are 
often the 
worst for 

Modes of 

tries to escape from his misery by killing him- 
self ; or when he hears a voice from heaven 
commanding him to destroy himself. Or, 
without delusion and without any feeling of 
wretchedness, there is sometimes an ungov- 
ernable impulse to self-destruction. Occasion- 
ally patients kill themselves accidentally, as 
when in a burst of wild excitement they try to 
escape from the house by jumping from the 
window, but such cases are not suicidal in the 
same sense as the others, for here there was 
not the intent to destroy life. 

The quiet cases that say nothing about their 
suicidal inclination or intention are in reality 
far more dangerous, and more likely to make 
a determined effort at self-destruction, than 
those who speak much about it. Hence we 
should be very vigilant with these quiet cases. 
Again, it must not be thought that a patient 
will not kill himself because he is afraid 
of being killed by others. On the contrary, 
this is one of the most common delusions of 
suicidal patients, and one that is very apt to 
throw the relatives off their guard. 

The most frequent modes of suicide are 
drowning, hanging, starvation, cutting, poison, 
using firearms, and precipitation. Sometimes 


the mere sight of the means of destruction, 
such as a sharp knife, rouses the suicidal im- 
pulse in the patient's mind. 

Similar to suicide is the propensity to self- 
mutilation, as when the patient tears out his 
tongue, puts out an eye, or chops off a 
finger. This is almost always delusional in 
its origin. 

Homicidal Acts. Under these we include Homicide, 
also the less severe forms of assault upon 
others. Such assaults may be made by a 
patient when trying to escape from restraint, 
or they may occur in a paroxysm of acute 
insanity ; in the wild excitement of acute 
mania, the patient may assault any one near 
him, without showing the reason that prompts 
his attack. More frequently it arises from 
hallucination of hearing, or other delusion, as 
when the patient thinks the assaulted person 
has been calling him abusive names or is his 
enemy. Or it may spring from the mere 
impulse to kill. In the insanity associated 
with epilepsy there is often intense irrita- 
bility; and these patients frequently make 
assaults, which may even be murderous, upon 
those near them, on the very slightest provo- 


Various Varieties of Insanity. The following names 

forms of • . 1 . r r • 

insanity. are given to the more common forms of insan- 

i. Congenital Imbecility and Idiocy. Mental 
feebleness or defect which has existed from 
birth or from infancy, — the mind never 
having reached its proper standard of devel- 
opment. The term imbecility is applied to 
the slighter degrees, and the term idiocy to 
the more marked degrees, of this congenital 

2. Melancholia. States of mental distress 
or suffering, the patient being always more or 
less wretched or unhappy (mental depression). 
There may be just the simple feeling of 
depression or dulness to a greater or less 
degree ; or delusions may be developed, which 
are of a more or less distressing character, and 
aggravate the condition. 

3. Mania. There is here exaltation or mor- 
bid activity of the mental powers, shown in 
excited conduct and speech, usually with 
delusions, but without any feeling of mental 
distress. The term monomania is often ap- 
plied to those cases in which the insanity 
shows itself mainly in fixed delusions limited 
to one subject or one set of subjects. 


4. Dementia. Mental feebleness similar to 
imbecility, but coming on in a person whose 
mental powers have previously been of a 
healthy standard. 

5. General Paralysis. This form of insanity General Par- 
results from degeneration and wasting of cer- symptoms, 
tain portions of the brain, and is marked by a 
combination of mental and bodily symptoms. 

The disease tends to increase more or less 
steadily, and is always fatal, the patient usually 
dying in from two to three years. Mentally there 
is a gradually increasing enfeeblement, which 
in the last stage of the disease is very pro- 
found ; often with periods of more or less acute 
excitement, delusions of great power and 
wealth, restlessness, and propensity to steal and 
hoard rubbish. This delusional condition often 
prompts the patient to engage in struggles and 
feats of strength which are beyond his power, 
and therefore attended with risk of injury. The 
bodily affection consists in a paralysis, which 
usually affects in the first place, the lips and 
speech, and gradually extends over the whole 
body, until the patient becomes utterly helpless. 
The power of swallowing is more or less im- 
paired, and there is thus risk of choking when 
food is being taken. The patient becomes 


wet and dirty in his habits, from loss of power 
over the bladder and bowels. The nutrition 
of the body is affected ; the bones become soft, 
and are then liable to be fractured by very 
slight violence. Convulsive seizures, similar 
to epileptic fits, often occur in general paraly- 
sis ; and there is also a liability to attacks of 
congestion of the brain, in which the patient 
lies unconscious as if in an apoplectic seizure. 
In the last stage of the disease there is great 
loss of flesh, bed-sores form, and the patient 
is in a very miserable plight. 
Epileptic in- 6. Epileptic Insanity. Associated with epi- 

sanity. . . 

lepsy we frequently find attacks of excitement. 
This excitement may come on before the fits, 
or after the fits, or may occasionally take the 
place of the fits ; and it is often of the wildest 
and most furious character. Delusions are 
common, and also hallucinations of sight and 
hearing. There is frequently great suspicious- 
ness ; and often the soreness and muscular 
pains which are felt after the convulsive seizure 
are attributed by the patient to rough usage 
by those near him at the time of the fit. As 
already mentioned, there is often intense irri- 
tability and quarrelsomeness, with great impul- 
siveness and deficient self-control, leading to 


violent and homicidal acts. Sometimes in a marked 

1 . . , J . result of 

these violent acts the patient is quite uncon- violence. 
scious of what he is doing. When epileptic 
fits recur frequently over a long period, there 
usually results more or less marked enfeeble- 
ment of mind. 



THE duties of an attendant on the insane 
are of a very responsible kind, and he is 
concerned in looking after both the bodily and 
the mental welfare of the patients under his 
importance Management of the Bodily Condition. Among 

or attending ° ** * ° 

carefully to the insane, iust as among; the sane, the mental 

the bodily ' J ° ' 

health. condition is very largely affected by the state 
of the body, by its well-being and comfort or 
by its derangement and discomfort ; and every- 
thing that tends to promote the bodily welfare 
has a direct and beneficial influence in pro- 
moting the mental health. Hence in all cases, 
and more especially in those in which the 
mental condition is such that the patient can- 
not take proper care of himself, everything 
possible should be done by the attendant or 
nurse, under the direction of the doctor, to 
preserve the bodily health, — to improve it if 
necessary, and to keep it up to a proper stand- 



ard. In studying the bodily functions (first 
section of the handbook) we saw the necessity 
of good ventilation, cleanliness, warmth, suffi- 
cient clothing, good and sufficient food, regular 
open-air exercise, undisturbed sleep, etc., for 
the proper discharge of these functions ; and 
it is necessary to attend to all these matters in 

the interest of our patients. The attendant Management 

. . of the Bod- 
should keep the day-rooms and the sleeping- iiy condition 

rooms scrupulously clean, tidy, well ventilated, sane. 
and sufficiently warm ; he should have the bed- 
clothing thoroughly aired at proper times, and 
kept clean and dry ; and he should see that 
the patient wears clothing suitable and suffi- 
cient for the season of the year. Cleanliness, 
both of person and of clothing, is absolutely 
essential. The attendant should be very par- 
ticular in seeing that the instructions of the 
doctor as to the amount of exercise or work to 
be done by the patient, the taking of medi- 
cines, and any other details of treatment, are 
accurately and punctually carried out. Suffi- 
cient time should be allowed for the taking of 
food; there should be no undue haste in re- 
moving the dishes ; and the attendant should 
see that each patient takes his food in sufficient 
quantity and in a proper way, duly masticating 



All the In 
sane are 

it. Attention to the bowels is necessary ; and 
this is especially important in cases of epilepsy 
and general paralysis, for in them derangement 
of the bowels is often the cause of an increase 
in the number and severity of the fits, or 
brings on the " congestive " attacks. During 
the night all noise or other source of disturb- 
ance should, as far as possible, be prevented 
in the sleeping-rooms. 

The various conditions which bear upon the 
bodily health have been already fully indicated 
in previous pages of the handbook ; and it is 
therefore unnecessary to enlarge further upon 
them here. In the second section of the hand- 
book instructions are given for special nursing 
in the cases of more pronounced bodily illness. 
A good attendant should consider that all the 
persons under his charge, even when they are 
not in the hospital ward of the asylum, a.rej>a- 
tients in the truest sense of the term, and require 
special care and management ; and many of the 
general instructions given in the second section 
are directly applicable in the treatment of all 
insane persons. 
Note and re- It is also the attendant's duty to take note 
change-fin of any symptoms of bodily derangement or 
symptoms, failing health, such as cough, breathlessness, 


loss of appetite, irregularity of the bowels, 
wasting of body, increasing feebleness in 
walking, etc., and to report them without 
delay to the medical officer, so that any treat- 
ment which is called for may be begun at 
once. It is likewise a good rule to examine 
the patient's person carefully every time he is 
being dressed or undressed or bathed, and to 
observe if there are any abnormal appearances, 
such as bruises, marks of injury, redness, 
swelling, eruptions o'n the skin, commencing 
bed-sores, etc. When found, these should be 
reported to the doctor at once. Patients of wet 
and dirty habits should be frequently attended 
to, and kept as dry and clean as possible ; and 
any medical directions given to prevent scald- 
ing of the skin should be carefully carried out. 
In some cases, especially in the advanced 
stage of general paralysis and in the stupor 
which follows a succession of epileptic fits, 
there is risk of choking, from paralysis of the 
power of swallowing ; and then all food should 
be given in a soft form, such as minced meat, 
milk, custards, and the soft part of bread, while 
hard food, such as crusts, should be avoided. 

Management of the Mental Condition. The Management 

° J of the mental 

arrangements of an asylum, its discipline and state. 


daily routine, are intended (i) to promote re- 
covery when that is possible ; (2) to secure 
that the patients shall be kept under due ob- 
servation ; and (3), in cases where recovery 
does not take place, to make the surroundings 
of the patients as favorable, healthy, and com- 
fortable for them as is possible, consistent 
with their safety and proper custody. It is 
therefore the duty of the attendant to make 
!iiiy°the Care ~ himself familiar with the arrangements and 
Rules of the regulations of the institution in which he is 

Asylum. o 

serving, and to carry them out in a loyal and 
conscientious manner. In most asylums the 
attendant, on beginning duty, receives a copy 
of the rules applicable to his work ; and he 
should carefully study these rules, and act up 
to them. 

For example, in one or more of the wards 
the patients may, by direction of the medical 
officer, receive a very considerable amount of 
liberty, because it adds to their contentment ; 
certain doors may be left open ; and the at- 
tendants are expected to supervise the patients 
without the aid of locked doors ; while in 
other wards, where the cases are not so trust- 
worthy, the doors are kept constantly locked, 
to prevent the patients passing away from di- 


rect observation. In these latter wards the 
doors should never by any negligence of the 
attendant be left unsecured at any time. And 
equally in the former wards the doors should 
be kept open at the stated times ; and the at- 
tendant has no right, unless instructed by one 
of the upper officers, to lock a door which is 
meant to be open, simply to save himself some 
extra bother in looking after a troublesome 

In the same way all the other arrangements importance 

J o . of the routine 

of the asylum, which are intended to secure work, 
the safety or promote the comfort of the pa- 
tients, should be intelligently carried out ; and 
the instructions for the routine work, such as 
raising the patients, the serving of meals, the 
bathing of patients, and their supervision 
when at work or taking walking exercise, 
should be carefully followed. The windows 
are usually " checked," so that they cannot 
open wide enough to let a person pass through ; 
and the shutters in the sleeping-rooms can, 
when necessary, be securely fastened. 

In the treatment of individual cases we try Treatment of 

, , - , . ill tne different 

to lead the mind into a more healthy groove mental states 
of action, to repress morbid acts or habits, 
and to train the patient to more healthy and 


correct habits. We endeavor to cheer the de- 
pressed by kindly, sympathetic conversation 
and conduct towards them, and to divert their 
thoughts from their distressing fancies by get- 
ting them to take an interest in the things 
around them, and by inducing them to engage 
in active work and amusement when their 
bodily health permits it. The noisy, turbulent 
cases should as far as possible be soothed by 
persuasion and judicious management, and 
kept from annoying their fellow patients. 
When the excitement is severe and long-con- 
tinued, we try to provide a healthy outlet for 
it in active muscular work or active open-air 
exercise. With the demented patients the at- 
tendant has more or less to think for them in 
everything. He has to see to their being dressed 
and undressed, to their getting their food prop- 
erly and going out for exercise, to their being 
protected from exposure to cold or other dan- 
ger, and to all the other routine of their daily 
life. Those patients who are impulsive and way- 
ward in their conduct should be encouraged 
to habits of better self-control. 
Do not With regard to delusions, these should never 

ridicule deiu^ be made a subject of thoughtless ridicule or 
ill-timed jesting. Neither argument, nor ridi- 


cule, nor flat contradiction will convince a pa- 
tient of his error; and he maybe needlessly 
annoyed and hurt thereby. It is much better, 
then, just to ignore the delusions as far as 
possible. The attendant should avoid bring- , 
ing them up in conversation, or doing anything 
which leads the patient to think about or ex- 
press them, and he should try to get the pa- 
tient to act as if the delusion had no exist- 
ence. Insane persons do not by any means 
always follow out their delusions to their logi- 
cal conclusion. A patient mav think he isThew'se, 

" t kindly and 

a king or the owner 01 the whole place, but temperate 

. , . ,., treatment of 

still sees nothing incongruous in helping like patients with 

,. . , i r i delusions. 

any ordinary person in the work 01 the 
house, or in taking his orders from the 
asylum officers ; and it is wise to encourage 
him in this habit, and thus quietly to ignore 
his delusion. If the patient speaks about his 
delusions of his own accord, we should just 
say firmly but temperately that we think he is 
wrong there, and then try to lead him away 
from the subject. Nicknames should never 
on any account be given to patients from their 
delusions, for doing so is just one way of 
keeping the idea constantly present to their 



Correct in- All those acts and habits which spring; from 

sane habits. x ° 

the diseased mental condition, and which are 
therefore morbid and unnatural, should be re- 
pressed as far as possible, and correct habits 
inculcated in their place. Thus destructive- 
ness and all other mischievous propensities 
should be checked. Slovenliness in dress and 
disorderliness in eating should be corrected, 
and the patients encouraged to be neat, tidy, 
and orderly. When food is refused, much may 
be done by tact in persuading the patient to 
take it. Sometimes patients, while refusing 
all food offered directly to them, will yet take 
readily anything they can steal or pick up un- 
observed ; and advantage may be taken of 
this peculiarity in getting them to take food. 
When forcible feeding is required, it should of 
course be done only under the immediate di- 
rection of the doctor. The eating of leaves, 
cloth, and other improper things, should be 
prevented, for the patient may thereby injure 
himself seriously. Some general paralytics 
are especially apt to eat ravenously, stealing 
the food from the plates of other patients, and 
cramming it in great pieces into their mouths, 
at the risk of choking themselves ; and this 
propensity should be guarded against. Dress- 


ing fantastically in obedience to a delusion 
should not be permitted. When wet and dirty 
habits are due to the mental condition, not to 
bodily paralysis, much may be done by assidu- 
ous attention from the attendant, and by train- 
ing the patient to attend to the calls of nature 
at certain regular times, to get him into more 
correct habits. 

This training to proper healthy habits not Promote 
only promotes the comfort of the patient, but g °° 
has a very direct effect in improving the men- 
tal state. And the attendant's exertions repay 
themselves well in the end, for the time and 
trouble bestowed on the patient at first save 
still more time and still more trouble with him 
afterwards, as well as prevent the discredit at- 
tached to his being found in an unsatisfactory 

The daily routine of the asylum is meant to 
help in carrying out these various indications 
for the treatment of the insane. The regular 
hours for rising, taking food, work, exercise, 
amusement, and retiring to bed, are beneficial 
not only to the bodily health, but also to the 
mental state, in making the patient lead a regu- 
lar life, and educating him in good habits. 
Occupation is a most important means in the 


1 08 


importance treatment of our patients. It is not the 

of regular 

occupation, amount and value of the work done that is 
here considered — it is that suitable occupa- 
tion, however simple in itself, by exercising 
alike the bodily and the mental powers, has a 
most salutary effect on both the body and the 
mind. It diverts the patient from his morbid 
fancies, and leads his thoughts into a healthy 
channel. Hence, whenever the bodily strength 
allows of it, we should try to get the patient to 
occupy his time usefully and engage in some 
work that is suitable and congenial to him. 
Such occupation is found in housework, in the 
garden or workshops, on the farm, in needle- 
work, in the laundry, in drawing, writing, or 
any other work which the patient is able for„ 
It is not enough for the attendant to take the 
patient out with the working party, and then 
let him lounge about idly : he ought rather to 
make diligent efforts to get every patient to 
engage in some steady work, however simple 
that may be. The willing must not be over- 
tasked ; and the idle are to be induced to 

Amuse- Suitable amusements, such as dancing and 

games, are of value in introducing variety and 
interest into the life of the patients ; and as 


many of the patients as possible should be en- 
couraged to join in them. 

The amount of liberty allowed to each patient Liberty, 

J . . guard against 

is of course regulated by the instructions of escapes, 
the doctor. Escape should as far as possible 
be prevented by watchfulness on the part of 
the attendants. Certain patients show them- 
selves more prone to escape than others ; and 
they of course require to be specially looked 
after. General paralytics, in the early restless 
stage of their disease, often make numerous 
attempts to escape in a foolish, aimless way. 
When an attendant takes a number of patients 
out for work or walking, he should know ex- 
actly how many are with him, and should on 
his return see that all have come back with 
him. It is a good practice also to go over the 
patients when they are at table, and at bed- 
time, and to see from the unoccupied chairs 
and beds if any are missing. 

The risks of suicide and homicide must be Precautions 
guarded against. When the suicidal propen- luldle. 
sity is known or suspected, the doctor usually 
gives instructions for the patient to be placed 
under special observation — that is, to be kept 
under the direct and constant supervision of 
one or other of the attendants. When this 


Precautions order is given, the attendant should carry it 

against > J 

Suicide. out faithfully. There should be no negligence, 
no allowing the patient to wander away from 
the room and get out of sight for a longer or 
shorter time, and no relaxing of the watchful- 
ness without direct permission from the doctor, 
for there is no knowing when or how a suicidal 
patient will attempt to carry out his intention. 
In passing him from the charge of one to 
another, the first attendant should, before 
relinquishing duty, see that the second attend- 
ant has duly taken him under his care. Such 
articles as scissors, razors, knives, etc., which 
may be used for suicidal purposes, should be 
carefully kept out of the patient's way. It is 
well to have these articles safely locked up 
when not in use. They should be counted 
when given out for use, and again when taken 
back, so as to ensure that none are left out. 
All medicines should be kept in a place of 
safety. It maybe necessary to examine the 
patient's pockets and clothing at frequent 
times, to see that he has not succeeded in 
secreting anything that may be used hurtfully. 
Melancholic patients are often at their worst 
in the early morning, just after waking a_;J 
before food has been taken ; while after break- 


fast, and as the day wears on, they get less 
wretched, and the suicidal desire is less 
marked. It is necessary, then, to see that the 
supervision is kept up carefully in the early 
morning, just as at other times ; and it is often 
advisable to give the patient some food, such 
as a cup of milk or warm coffee, immediately 
on his waking. 

Homicidal assaults may best be guarded Precautions 

i i t i i • t • against 

against during the day by having the patient Homicide, 
suitably occupied, by judicious supervision, 
and by having a sufficient number of attend- 
ants to be able to control the patient thor- 
oughly if required ; while at night the patient 
may be made to sleep in a room by himself. 
When a dangerous patient has a special dislike 
to any attendant or patient in the same ward, 
it should be reported to the doctor, who will 
separate them by removing one or other to 
another ward. The irritability after epileptic 
fits is often best treated by persuading the 
patient to lie down in bed and rest quietly 
away from his fellow-patients. 

Struggles with patients should always be Avoid 
avoided if possible. This is, for reasons 
already indicated, particularly important in the 
case of epileptics and general paralytics. 



Never use 
force single- 

When it is necessary to use force, the attend- 
ant should not, unless there is no help for it, 
attempt single-handed to struggle with the 
patient. It is far better to summon assistance 
and get several attendants together, when the 
patient, seeing that resistance is useless, will 
often submit quietly ; or, if a struggle is still 
necessary, the patient can now be mastered 
thoroughly and with sufficient ease, so that the 
risk of his receiving any injury during the 
struggle is lessened as much as possible. In- 
experienced attendants often think it a weak 
thing to get assistance, and pride themselves 
on managing a troublesome patient without 
aid from others. This is a grave mistake. It 
leads to personal struggles with patients, which 
ought never to occur ; and these struggles are 
often dangerous to both parties, and are always 
injurious by the bad feeling they create. In 
certain circumstances, indeed, it behooves the 
attendant simply to leave the patient and get 
out of his way ; and there is not only no cow- 
ardice, but there is real wisdom, in such a 
course, if the patient, while morbidly irritable 
and quarrelsome, can be safely left alone. 
Struggles with patients ought to be immedi- 
ately reported to the doctor. 



Other exigencies in particular cases call for other 
appropriate management. Thus, with new 
patients it is well to keep them under more 
particular observation for a time at first, until 
their propensities can be known, and a trust- 
worthy idea formed regarding their mental 
state. In the insanity of old age there is 
often great restlessness, along with great 
bodily frailty. This increases the risk of 
accidental injury ; and sometimes the restless- 
ness is so incessant as in itself to exhaust the 
patient's strength. These dangers must be 
guarded against, and the patient got to rest as 
much as possible. Epileptics should be pre- 
vented from engaging in work or getting into 
situations (such as going too near an unguarded 
fire or being left alone in the bath) which 
would be dangerous if a fit were to occur. 
Treatment which benefits the fits has usually a 
correspondingly good effect on the mental state ; 
and any medical directions given with this view 
should be carefully carried out. When par- 
alysis is present, it is necessary to guard the 
patient more carefully from risk of injury ; the 
bodily health has to be specially looked after ; 
and the danger of choking, of scalding from 
the wet habits* etc., has to be kept in mind. 


Report As with the bodily, so with the mental state ; 

changes in 

the mental the attendant should endeavor to notice any 


changes or new symptoms, such as greater 
restlessness, greater dulness, any delusions 
expressed, attempts to escape, or other pecu- 
liarities of conduct, etc., and should report 
them to the doctor at his next visit. 
Attendants In their personal intercourse with the pa- 

should carry . 

out their tients, the attendants should remember that 
firmness, example is better than precept. They should 
constant 'self- themselves, therefore, be examples of neatness, 
tact. ' punctuality, and orderly conduct ; and should 
always bear themselves with courtesy and 
respect towards both their fellow-attendants 
and the patients. Few persons can exercise 
control over others, especially if they are 
weak, without tending to abuse it ■; and the 
position of authority in which attendants are 
placed is specially apt to be abused by coarse 
and unfeeling persons. This must be guarded 
against, and attendants should bear in mind 
that the power over their unfortunate fellow- 
creatures entrusted to them is to be exercised 
always justly and considerately, never for the 
purpose of gratifying any personal wish for 
retaliation, or the mere vain-glorious desire .of 
lording it over others, but always with a single 


eve to the welfare of the patient. They should The insane 

"', . ; , not fully re- 

remember that the insane are not fully respon- sponsible. 
sible for their actions, and should therefore 
not resent rude language or rough conduct 
from them, but show constant self-control and 
kindliness as well as firmness towards them. 
It is most difficult to distinguish the annoying 
speech and conduct of many insane pa- 
tients from the bad conduct of sane people, 
which would deserve punishment. For such 
insane conduct attendants must never, on any 
account, resort to punishment. They should 
report it fully to the doctor, and he will adopt 
the proper means for checking it in a medical 
way, which will have far more effect than the 
summary treatment of an attendant, just as 
society is far better governed by a magistrate 
dealing with offenders than by each man 
taking the law into his own hands. Attend- 
ants should not make a promise to a patient 
unless it is to be fulfilled. They should try to Sympathetic 

, r , - , , , and consider- 

win the confidence ot the patients by sympathy, ate treat- 
kindness, and due consideration for their feel-" 
ings. They should not hold themselves aloof 
from their charges, or be content with super- 
vising them, but should join heartily in their 
occupations and amusements, and work both 


Personal in- with and for the patients. Much may be done 

fluence. . J 

by personal influence ; and a patient will often 
be docile and quiet with one attendant who 
guides him in the right way, when under 
another attendant he would be very trouble- 
some. When it is necessary to refuse requests 
by patients, or to enforce control over them, 
attendants should constantly refer to their 
"rules "'as their reason for doing so, rather 
than their own will, for thus there is much less 
feeling of irritation roused in the patient. 
Above all things, remember that " a soft 
answer turneth away wrath." No maxim is of 
more value in dealing with the insane, or will 
save an attendant more trouble in the end. 
These duties call for the exercise of much 
tact, that knack of knowing how best to 
manage a patient, which cannot be taught on 
paper, but which can be acquired when there 
is forgetfulness of self and an earnest desire 
to do the best for the patient. 



Home The attendance on those suffering from 

Treatment. , .. . . 

mental disease in their own homes, or in 
lodgings, is now one of the recognized 


branches of nursing. Few patients in the 
higher classes are sent to asylums without 
home treatment having been tried in the 
earlier stages of the disease. A good attend- 
ant is of incalculable value in the home treat- 
ment of a case of insanity. Through such 
services, attacks may be cut short, infinite 
anxiety and risks saved to patient and rela- 
tives, accidents avoided, suicides averted, and 
valuable lives restored to reason. 

The chief differences between treating a Differences 

, , . .... i r 1 between 

case at home and in an institution are the tol- Home and 

, . Institution 

lowing : Treatment. 

(1) Less help can be got either from fel- 
low-attendants or doctors, and therefore more 
forethought and observation of the patient's 
symptoms more resource and self-command, 
are needed. (2) The risks are far greater 
from stairs, open windows, razors, knives, etc. ; 
and therefore the first thing an attendant in 
charge of a patient at home must do, is care- 
fully to obviate such risks, by taking posses- 
sion of keys, removing bolts from inside of 
water-closets, checking windows, arranging 
for rooms on the ground floor, and putting 
away knives and razors. (3) The difficulties 
of getting the patient to take food, medicines, 



Differences and exercise, are much greater ; therefore, if 
Home and these things can't be done by tact and persua- 

Institution . , . .,-, iiii n • i 

Treatment, sion, the patient will probably have to do with 
less of them than he needs. A patient will 
usually be found to be much worse to control 
in his own house than anywhere else, and 
more apt to resist interference with his liberty. 
(4) The relatives of the patients will often 
be suspicious, or lose their heads from fear, or 
be fussy or positively obstructive ; therefore an 
attendant must be patient but firm with the 
relatives and friends, and above all things get- 
ting the doctor in attendance to give explicit 
orders for the course adopted, and to take the 
responsibility of the instructions required. It 
is in many cases better if the doctor will sug- 
gest that the patient should be left with his at- 
tendant without relatives coming in to inter- 
fere too much. (5) The labor is more ex- 
hausting, being often night and day work. 
An attendant should tell before his own 
strength and nerve are giving way and ask 
for assistance. (6) A good attendant can 
help the doctor in attendance greatly, by 
keeping a daily written note of : (a) the food 
taken, (b) the amount of sleep, (c) the length of 
time in the open air, (d) the patient's tempera- 

in private; houses. 119 

ture, (e) the. chief mental symptoms, with the 
changes that take place in them, (/) the pa- 
tient's weight, if possible, every week, if the 
case is long continued. Such observations 
are very good for the attendant himself, and 
give confidence to the relatives of the patients. 
(7) It falls more directly on the attendant than 
in an asylum to note whether the patient is 
in any way suicidal, and to take measures for 
his being properly watched. No mental nurse 
should ever go to a case without thinking of 
the question of a suicidal tendency. (8) As 
his position is isolated, he should ask the doc- 
tor very minutely about the treatment and 
contingencies, and tell fully about his difficul- 
ties, and he should report all struggles with 
the patient, etc. (9) As he should be above 
suspicion, it is usually better not to take any 
alcoholic stimulants at all while on duty. 

To have the care of a few cases in their own Home treat- 

i • i i • • i r ment en- 

nouses, or in lodgings, is very good for an at-iargesknowi- 
tendant trained in an institution. It makes leases 
him more watchful, more self-reliant, and more bmty. nsi " 
thoughtful, and he feels his own responsibility 
and the importance of his duties more. He 
should keep his place as the patient's nurse, 
and not mix with the servants, and, above all 


things, should not gossip, either in the house 
or out of it, about the patient's symptoms. 
Most likely he will at first be looked on with 
some suspicion or jealousy by those in the 
house, therefore he ought to be very prudent 
The reward in his conduct ; but if he does his work well, 

of careful - . . . ' 

nursing. and the case turns out satisfactorily, he will 
often be rewarded by the gratitude and good 
will of his patients and their relatives. 





LL attendants and servants shall sign 
some such declaration as the following : 

I hereby promise to obey the rules of the institution, Declaration 
to faithfully execute the orders that may be given me ™ndants and 
by my superior officers, and to perform any duty as- Servants, 
signed to me, although not of the kind for which I am 
chiefly engaged. I consider myself bound to promote 
the objects of the institution, to do my best to further the 
recovery of the patients, and to secure their comfort and 
safety. I also undertake not to bring into the institu- 
tion any intoxicating liquors ; to be careful of its prop- 
erty ; to avoid all gossip as to its inmates or affairs ; and 
to endeavor generally, by my own conduct and de- 
meanor, to sustain its reputation. If anything improper 
be done in my presence, or to my knowledge, I pledge 
myself to lose no time in reporting it to the medical 
superintendent or one of the superior officers. I un- 
derstand my engagement to be monthly, and agree to 
give one calendar month's notice should I wish to 
leave my situation. I acknowledge the right of the 
medical superintendent to discharge me without warn- 



ing, and with forfeiture of all wages, for acts of harsh- 
ness or violence to patients, intemperance, or disobe- 
dience to orders. 

Summary of The duties and obligations of attendants 
are briefly set forth in the declaration, and 
all instructions and regulations for their guid- 
ance amplify that declaration, and inform 
them how the recovery, safety, and well-being 
of the patients are provided for. These duties 
require the enduring exercise of kindness and 
firmness, sobriety of demeanor, and an intelli- 
gent carrying out of rules and orders. This 
service, like all others, requires to be learnt, 
and it is therefore necessary that attendants 
should make themselves familiar with the con- 
tents of this book, and give careful attention 
to the instructions received from their superior 
officers. They must always remember that 
their position is one of great trust and respon- 
sibility ; and that they have the care of those 
who, through affliction, cannot care for them- 
selves ; and that upon them the recovery, com- 
fort, happiness, and safety of the patients, in 
great measure, depend. 

Exemplary Attendants should be examples of propriety 


necessary, of conduct, order, personal neatness, and per- 
fect truthfulness. They are enjoined to do 


their utmost to occupy and amuse every pa- 
tient, no matter what the mental condition 
may be. They shall treat all with impartial 
consideration, and are expected to exercise 
such tact as will comfort the depressed, soothe, 
the excited, and check the impulsive, irritable, 
and destructive. They shall also use every 
endeavor to render the wards interesting, 
beautiful, comfortable, and home-like. In the 
employment of patients, the attendant must 
work with them, and make it appear that they 
are assistants, and not servants, and no patient 
is to be overtasked. In their amusements all 
should participate, and none be excluded. 

All attendants are under the authority of Distribution 
the medical officer and the heads of their re- 
spective departments. The charge attendant 
in each ward is responsible for its manage- 
ment, and the safety and safe custody of the 
patients in it, and this responsibility is shared 
in by the ordinary attendants. During the 
temporary absence of the charge attendant, 
the second attendant undertakes the duties. 
These duties include more especially the ad- 
ministration ] o£ medicines, etc., the reporting 
of the symptoms and peculiarities manifested 
by the patients, of any misconduct on the part 


of the attendants, the general management of 
the ward, and the safe-keeping of the property 
of the institution, and of the patients con- 
tained in it. The charge attendant shall also 
send in such reports and keep such books and 
lists as may be required. They shall also 
number the patients from time to time, at 
meal hours, when going out for exercise, and 
when going to bed, and accompany the medi- 
cal officers on their rounds. 
Cruelty or Any act of neglect, harshness, or cruelty to- 
wards patients will be punished with the ut- 
most rigor, in accordance with the provisions 
of the lunacy acts. Act 16 and 17 Vict. Cap. 
97, sec. 123: "If any superintendent, officer, 
nurse, attendant, servant, or other person, em- 
ployed in any asylum, strike, wound, ill-treat, 
or wilfully neglect any lunatic confined therein, 
he shall be guilty of a misdemeanor and shall 
be subject to indictment for every such of- 
fence, or to forfeit for every such offence, on a 
summary conviction thereof before two jus- 
tices, any sum not exceeding twenty pounds 
nor less than two pounds.'' Also 20 and 21 
Vict. Cap. 71, sect. 99 : " If any superintend- 
ent, inspector, officer, or servant, or other per- 
son employed in any public, private, or district 


asylum or house, or otherwise having the care 
of any person detained as a lunatic patient . . . 
shall wilfully maltreat, abuse, or neglect any 
person, so detained, to the injury of such per- 
son, such superintendent, inspector, officer, or 
servant, or other person, shall be guilty of an 
offence, and for every such offence be liable in 
a penalty not exceeding one hundred pounds, 
or to be imprisoned for any period not exceed- 
ing six months.'' Attendants are warned that 
they must prevent one patient from ill-treating 
another, and will not be allowed to delegate 
their duties to patients, except as may be ex- 
pressly sanctioned. They must instantly re- 
port any ill-treatment, and any attendant con- 
cealing such conduct will be deemed guilty, 
and dealt with accordingly. Attendants are 
specially warned against mimicry, deception, 
or irritation of patients. A respectful de- 
meanor towards them must be maintained, 
and no vindictive feelings expressed, or pro- 
fane language used. 

Should it be absolutely necessary to employ Employment 
force, it must never be used by a single at- 
tendant, except in the most urgent circum- 
stances ; but additional assistance must be 
immediately procured, and one of the superior 


officers at once summoned, when possible, be- 
fore force is resorted to. Should a struggle 
be unavoidable in controlling violence, the 
knees must never be placed on the body of 
the patient. Fatal injuries have often been 
unintentionally caused in this way. On no ac- 
count are the limbs to be twisted. 
Privation, No patient shall be subjected to any priva- 

Punishment, . . _ . . . 

etc., forbid- tion, seclusion, or mechanical restraint, with- 
out a special order from the medical superin- 
tendent or his deputy. By seclusion is meant 
the placing of a patient alone in any locked 
room or locality during the daytime. By 
mechanical restraint is meant any restriction 
of the bodily liberty of a patient by some 
appliance — such as a rope or strait-jacket. 
In case of great and sudden violence a patient 
may be placed in a room alone, but the door 
must not be locked, and the circumstances are 
to be at once reported to the head attendant. 
No patient is to be detained in bed, or placed 
in bed before the stated time, without the 
sanction of the head attendant. 

Supervision The attendants shall exercise a constant 
supervision over the patients entrusted to 
them, except such as are on parole. . They 
shall not remain in their rooms during the 


day, nor shall they leave their wards during 
hours of duty, except in the discharge of duty. 
No ward is to be without the supervision of an 
attendant, when it contains patients not on 
parole. Special and unceasing attention must 
be devoted to newly admitted patients, to the 
suicidal, dangerous, destructive, dirty, and 
those prone to escape ; and it must not be 
forgotten that many seemingly quiet patients 
are, at times, liable to become dangerous to 
themselves or others. When patients are 
being transferred from one ward to another, 
they must be accompanied by an attendant, 
who will personally intimate their arrival to 
the attendant in charge of that division. 

Reports as to patients are not to be made Personal 
in the hearing of those referred to, nor are epo1 
attendants to reply to the complaints of pa- 
tients unless requested to do so. The follow- 
ing call for an immediate or special report : — 
accidents ; violence ; refusal of food ; difficulty 
in swallowing ; bodily illness ; extraordinary 
mental symptoms ; eruptions on the skin ; 
shive rings ; fits ; unusual threatening language 
(suicidal or homicidal) ; depression of spirits, 
or attempts at escape. 

There must be no alteration of the treatment 


No Change of any patient without the express sanction of 

of Medical . . 

Treatment the medical officers. No patient shall be 
taken beyond the grounds without permission ; 
and no patient shall be allowed to absent him- 
self from out-door exercise except by reason 
of sickness, dangerous excitement, or other 
similar causes. The hours of work must be 
rigidly adhered to, except as may be specially 

Food, Medi- The meals must be served punctually, neatly, 

cines, etc. 

expeditiously, and be equally distributed. The 
patients must have due time to eat their food 
before the table is cleared, and any defect in 
its quality or quantity is to be reported to the 
medical superintendent. 

All articles of sick dietary must be properly 
administered, and only to the patient for 
whom they are supplied. Wine, or other stim- 
ulants, and medicines, are to be punctually 
and carefully given, and always strictly accord- 
ing to directions. 

Attendants must slowly and carefully feed 
such patients as cannot feed themselves, and 
never use force in so doing. Patients on 
minced meat are to be effectually guarded 
against the risk of partaking of the ordinary 


Attendants shall exercise every precaution Dangerous 

. . . ,. . Articles. 

in regard to keys, razors, scissors, medicines 
(including disinfectants), etc. ; and any loss 
must be immediately reported to the head 

Keys must be constantly worn on the person 
and displayed as little as possible. They are 
not to be lent to patients, nor taken beyond 
the bounds of the institution without sanction. 

Knives and forks, scissors, etc., must be used 
only in the immediate presence of an atten- 
dant, and at all other times must be kept 
locked up. 

Broken glass and crockery must be entirely 
and immediately removed. 

Such dangerous places as lifts must be kept 
locked when not actually in use by the atten- 
dants, and every precaution taken to prevent 
accidents there. 

The greatest care is to be taken to lock up 
all medicines in the safe places provided for 
them, never to permit any patient to handle 
them, and not to serve out more than the exact 
dose indicated by the label. 

Suicidal patients must be most carefully Suicidal 
searched on going to bed, and kept under 
special supervision. 


Fire. Every possible precaution must be used to 

guard against the danger of fire, in accordance 
with the special rules in force. 

Coals must not be heaped high on grates. 

No fire is to be left burning without being 
protected by a wire fire-guard, when such are 

No inflammable materials are to be placed 
near the fire-places. 

Only such matches as are issued from the 
stores may be used, and none given to patients. 
Burning materials are not to be carried about, 
nor are lighted matches, etc., to be thrown on 
the floor. 

Attendants must supervise the lighting and 
mending of the fires themselves, and keep the 
necessary materials in the places allotted to 
them when not in use. 

Charge attendants must see that all fires in 
their wards are low, and carefully protected, 
before going to bed. 

All gas-lights must be carefully turned out 
at the proper time. An escape of gas must be 
reported at once, the room freely ventilated, 
and on no account approached with a light. 

Should a fire occur, all are expected to 
retain their presence of mind, to set all appli- 


ances provided in immediate action, to summon 
aid, and to secure the safety of the patients 
as detailed in the rules and regulations hang- 
ing in each attendant's room. 

It is necessary for the health of the house- cleanliness # 
hold that all impurities should be removed astution. 
fast as they are produced ; that daylight and 
fresh air should be freely admitted ; that the 
air of the wards should be warm and dry ; and 
that there should be a plentiful supply of clean, 
fresh water. Every part of the house is liable 
to inspection, and must be scrupulously clean, 
Attendants will therefore see that there is a 
speedy and thorough removal of all house- 
refuse and filth from the building and its 
neighborhood, and frequent and complete 
cleansing of such sculleries, closets, etc., as 
require it. They shall give constant attention 
to the ventilation of the wards, and endeavor 
to keep them supplied with pure air, free from 
draughts and at a temperature of 58 . Re- 
mains of meals must be carefully returned 
with the dishes to the kitchen, and broken 
fragments removed as swill, together with the 
ashes and other refuse, as may be directed. 

The attendants are responsible for the cleanliness 

... r 11 • 1 1 • 1 °f Inmates. 

cleanliness or all patients under their charge, 


and must give special attention to those who 
are of dirty and destructive habits. Soiled and 
torn clothing must not be permitted at any 

Laundry. The soiled articles are to be sent to the 

laundry at the appointed times, with an accu- 
rate list of every item, which must be duly 
marked with the name of the owner or ward 
number. Deficiencies are to be reported at 

Special care is to be taken in regard to the 
clothing of patients suffering from infectious 
or contagious diseases. It must be sent to the 
laundry separately, and the laundress must be 
made aware of the nature of the bundle. By 
scrupulous attention to such means, infectious 
diseases may be in great measure stamped out. 

No waste. Attendants shall see that there is no waste 
permitted, and charge attendants shall be 
responsible for the furnishings of their wards 
and the property of the patients therein. They 
shall keep an inventory of all these articles, 
and see that everything is kept in proper 
repair and in accordance with their lists. All 
old articles must be produced to the head 
attendants before being condemned and re- 


On the admission of a patient, the attendant Admission of 

r # / # Patients. 

in charge shall lose no time in ascertaining 
the habits, tendencies, and condition of the 
patient, as indicated by the patient and as set 
forth on the notice of admission. It is of great 
moment for the protection of the attendants 
that all bruises or injuries should be noted at 

Charge attendants shall see that all patients Evening 
are safe in bed without having secreted clothes 
or other articles in the bed-rooms, except such 
as are permitted to do so by special sanction. 
The night attendants will take charge of the pa- 
tients by making a round of inspection with the 
charge attendants before going off duty, and 
receive their instructions. 

The day attendants will take over the Morning 

, J ■■", . . Duties. 

charge of the patients in the same way. 
Charge attendants shall every morning person- 
ally inspect every patient and ascertain the 
bodily condition and the state of the bed-room. 
No patients, except ward helpers, are to be 
placed in the day-rooms in the morning until 
the latter are made clean, warm, and comfort- 
able in so far as possible. 

Attendants who wilfully neglect or connive Escapes, 
at the escape of a patient are liable to prose- 


cution ; and when a patient escapes through 
the carelessness of an attendant, a portion or 
the whole of the expense of bringing back 
such patient to the asylum may be deducted 
from the wages of that attendant. 

Baths. The special bath-rules in force in every asy- 

lum are to be strictly observed, for many pa- 
tients have died in baths. Every precaution 
is to be used against accident in the bath- 
room, the thermometer is to be used as or- 
dered, and the bath is not to be used except 
in the immediate presence of an attendant. 
The cold water must always be turned on be- 
fore the hot, and no patient is to be bathed in 
water of higher temperature than ioo°, except 
by medical order. 

Private Attendants shall not cause the patients to 


work for them ; nor shall they work for them- 
selves during hours of duty without the per- 
mission of the medical superintendent. 
No pets ai- No pet animals are allowed within the asy- 

lowed. =, . . r i vi 

lum, except by permission of the medical super- 
Localities The male department is absolutelv forbidden 

forbidden. x 

to all females, and the female department to 
all males, except in the execution of some duty 
expressly sanctioned by the medical super- 


intendent. Attendants of each sex must al- 
ways be present on these occasions. The 
kitchen and laundry are forbidden to attend- 
ants except in the discharge of assigned 

No attendant shall relate out of the asylum Gossip, etc. 
anything connected with its inmates or affairs. 
They shall not hold communication with the 
patients' friends, nor permit gossip with the 
outside public. They shall not introduce 
books or papers without the sanction of the 
medical superintendent, and they shall be 
careful to hand all letters, etc., written by 
patients to him. 

Visitors are admitted to the visiting-rooms visitors, 
only, except by special permission of the medi- 
cal officer. 

As at all other times, a patient while being 
visited by friends must be kept under con- 
stant observation, except by special permis- 
sion, which is to be obtained on each occasion. 

Visitors to attendants must be first an- 
nounced to the head attendants, and on no 
account are such visits to unduly interfere 
with the work of the asylum. 

The leaves of absence are arranged by the Leave of 
medical superintendent, on as liberal a scale as 


possible ; but it must be distinctly understood 
that no leave can be claimed as a right. Be- 
fore going out, attendants shall see that com- 
plete provision is made for the performance of 
their duties during their absence, and that the 
attendant relieving them is informed of the oc- 
currences since the last medical visit. In the 
absence of any attendant, the others in the 
ward shall be held responsible for the dis- 
charge of his duties. 

Nothing shall be carried out of the asylum 
without a written pass from the head attend- 

Testimoni- No attendant or servant will be entitled to 
a certificate granted by the medical super- 
intendent under one year's service. 

The foregoing instructions apply to all per- 
sons in the employment of the institution, in 
so far as regards their intercourse with the 

pensions or These duties are very trying and difficult. 
The remuneration and privileges of efficient 
attendants will, therefore, be as liberal as pos- 
sible ; and special aptitude for work will as- 
suredly receive recognition and reward. In 
those asylums where pensions or bonuses are 
given, the rewards granted to attendants will 



be proportionate to their services ; and attend- 
ants are reminded that there are no better tests The Test of 
of their efficiency than the amount of benefit 
derived by patients through their exertions, the 
happiness of those in their charge, and the 
good report of convalescents.